a child is injured on the school playground and appears to have a fractured leg the first action the school nurse should take is a child is injured on the school playground and appears to have a fractured leg the first action the school nurse should take is
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HESI LPN

Practice HESI Fundamentals Exam

1. A child is injured on the school playground and appears to have a fractured leg. What action should the school nurse take first?

Correct answer: C

Rationale: The correct first action for the school nurse to take when a child is injured and appears to have a fractured leg is to assess the child and the extent of the injury. This initial assessment is crucial to determine the severity of the injury before proceeding with further interventions. Option A, calling for emergency transport, should only be done after assessing the extent of the injury. Option B, immobilizing the limb and joints, is important but should come after the initial assessment. Option D, applying cold compresses, is not recommended for suspected fractures as it can exacerbate swelling and pain.

2. A client is prescribed clonidine 0.1 mg/24 hours via a transdermal patch. Which client outcome would indicate that the medication is effective?

Correct answer: D

Rationale: Clonidine is an antihypertensive agent that works centrally to reduce blood pressure. A significant decrease in blood pressure, such as changing from 180/120 to 140/70 mm Hg, indicates that the medication is effectively managing hypertension. Monitoring blood pressure levels is crucial in assessing the response to clonidine therapy. Choices A, B, and C are incorrect as they do not directly relate to the therapeutic effect of clonidine in managing hypertension, which is the primary goal of the medication in this scenario.

3. A postoperative client has a prescription for ketorolac 30mg IV q6h. Which response demonstrates that therapeutic levels of the medication have been achieved?

Correct answer: C

Rationale: The correct response is to perform a pain assessment using a numeric scale. Ketorolac is an NSAID prescribed for pain relief. Monitoring pain levels is crucial to evaluate the therapeutic effectiveness of the medication. Pain assessment helps determine if the medication is providing adequate pain relief, indicating that therapeutic levels have been achieved.

4. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?

Correct answer: C

Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.

5. Which nutrient is an example of a macronutrient?

Correct answer: A

Rationale: Proteins are indeed macronutrients as they are required by the body in larger quantities for various functions such as growth, repair, and energy production. Choice B, minerals, are micronutrients needed in smaller amounts for various physiological processes. Choices C and D, water-soluble vitamins and fat-soluble vitamins, respectively, are also micronutrients that play essential roles in the body but are not classified as macronutrients.

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