a client being discharged following abdominal surgery will be performing his own dressing changes at home it is most important for the nurse to includ
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?

Correct answer: A

Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.

2. A healthcare professional is preparing to perform denture care for a client. Which of the following actions should the professional plan to take?

Correct answer: B

Rationale: The correct answer is to brush the dentures with a toothbrush and denture cleaner. This action ensures effective cleaning of the dentures. Dentures should be rinsed with cool or lukewarm water, not hot water, to prevent damage. Placing the dentures in a clean, dry storage container is not the immediate next step after cleaning; they should be kept moist to prevent warping.

3. During the admission assessment of a terminally ill male client, he states that he is agnostic. What is the best nursing action in response to this statement?

Correct answer: B

Rationale: The best nursing action in response to a terminally ill client stating their agnostic beliefs is to document the client's spiritual assessment. By documenting this information, the healthcare team can ensure that the client's beliefs are acknowledged and respected in their care plan. Providing information about the chapel's hours or inviting the client to a healing service may not align with the client's beliefs and preferences. Offering to contact a spiritual advisor of the client's choice may not be necessary if the client has clearly stated their agnostic beliefs, as they may not wish to engage in spiritual counseling.

4. When evaluating care of an immobilized patient, which action will the nurse take?

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

5. After completing an assessment and determining that a client has a problem, what should the LPN/LVN do next?

Correct answer: A

Rationale: After identifying a problem in a client, the next step for the LPN/LVN is to determine the etiology or cause of the problem. Understanding the root cause of the issue is essential as it guides the development of appropriate interventions. Option B, prioritizing nursing care interventions, is premature without knowing the cause of the problem. Option C, planning appropriate interventions, also relies on knowing the etiology first to ensure the interventions directly address the underlying issue. Collaborating with the client to set goals, as mentioned in option D, is important but typically comes after understanding the cause of the problem to ensure the goals are relevant and effective.

Similar Questions

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