Fundamentals HESI

Correct Answer: D

Rationale: The client in this scenario is in the illness stage of infection. During this stage, the individual exhibits specific symptoms such as a severe sore throat, pain when swallowing, and swollen lymph nodes. The prodromal stage precedes the appearance of specific symptoms and is characterized by nonspecific signs. The incubation period occurs between exposure to the pathogen and the onset of symptoms. Convalescence is the recovery period following the resolution of the infection. Therefore, the correct answer is 'D: Illness' as it aligns with the symptoms presented by the client.

Correct Answer: B

Rationale: To calculate the correct dose of 15 mg, the LPN/LVN should administer 1.5 ml of Lasix (20 mg/2 ml). This calculation ensures precise dosing. Choice A (1 ml) is too low and would provide only 10 mg, while choice C (1.75 ml) and choice D (2 ml) would exceed the prescribed dose, resulting in potential adverse effects. It is important for the LPN/LVN to administer the exact prescribed dose to ensure therapeutic efficacy and avoid unnecessary complications.

Correct Answer: A

Rationale: Seclusion should only be used when necessary and with proper documentation; otherwise, it may be considered unlawful. Placing a client in seclusion without a clear indication or proper documentation could lead to legal ramifications, making choice A the correct answer. Choice B is incorrect because assault and battery do not apply in this scenario. Choice C is incorrect as there is no mention of the client posing an imminent threat due to a history of violence. Choice D is incorrect as seclusion should not be used solely to maintain the therapeutic milieu but rather for the safety of the client and others.

Correct Answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

Correct Answer: A

Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.