a 73 year old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall in reviewing hip precautions with
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Nursing Elites

HESI LPN

Practice HESI Fundamentals Exam

1. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan?

Correct answer: B

Rationale: The correct instruction to include in the teaching plan for a client who had a hemiarthroplasty of the left hip is to 'Place a pillow between your knees while lying in bed to prevent hip dislocation.' This technique helps maintain proper hip alignment and prevents dislocation during the postoperative recovery period. Choice A is incorrect because bending at the waist to reach items on the floor can strain the hip joint and is not recommended following hip surgery. Choice C is incorrect because using a walker alone without assistance can increase the risk of falls and injury, especially in the immediate postoperative period. Choice D is incorrect because pain medication should be taken as prescribed by the healthcare provider, not specifically timed after physical therapy sessions.

2. When reviewing EBP about the administration of O2 therapy, what is the recommended maximum flow rate for regulating O2 via nasal cannula?

Correct answer: A

Rationale: The correct answer is to regulate O2 via nasal cannula no more than 6L. This flow rate is generally recommended to ensure adequate oxygen delivery without causing discomfort or potential harm to the patient. Choices B, C, and D are incorrect as they suggest flow rates that are either too low (2L, 4L) or too high (8L). A flow rate of 2L might not provide sufficient oxygen, while 4L could be inadequate for some patients. On the other hand, a flow rate of 8L could be excessive and potentially harmful, leading to complications like oxygen toxicity. Therefore, the optimal recommendation is to regulate O2 via nasal cannula at a maximum of 6L to balance effectiveness and safety.

3. When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?

Correct answer: A

Rationale: The correct answer is A because a second nurse should verify and enter the prescription into the client’s medical record to ensure accuracy. This step is crucial to prevent errors in transcription and administration. Choice B is incorrect as having another nurse listen to the phone call does not ensure accurate transcription. Choice C is incorrect because the provider clarifying the prescription upon signing the health record does not replace the need for proper documentation. Choice D is incorrect because the 'read back' process is essential for all telephone prescriptions to confirm accuracy and prevent errors in transcription or administration.

4. A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?

Correct answer: C

Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.

5. An 18-year-old client is admitted to the intensive care unit from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebra. The nurse's priority assessment should be

Correct answer: C

Rationale: Injuries at the level of the 2nd cervical vertebra can affect the phrenic nerve, leading to potential impairment of respiratory function. Assessing respiratory function is crucial as compromised breathing can quickly escalate to life-threatening situations. While response to stimuli is important, ensuring adequate oxygenation takes precedence due to the immediate threat to life. Bladder control may be affected by spinal cord injuries at higher levels, but it is not the priority in this scenario. Muscle strength is a potential consequence of cervical spinal cord injury, but assessing respiratory function is more critical in the acute phase.

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