a client with a history of asthma presents to the emergency department with difficulty breathing and wheezing which of the following is the priority n
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A client with a history of asthma presents to the emergency department with difficulty breathing and wheezing. Which of the following is the priority nursing action?

Correct answer: A

Rationale: In a client with a history of asthma experiencing difficulty breathing and wheezing, the priority nursing action is to administer a bronchodilator. This intervention helps relieve bronchospasm and improve the client's breathing. Obtaining a peak flow reading can provide additional information but is not the immediate priority in this situation. Providing supplemental oxygen may be needed but addressing the bronchospasm with a bronchodilator takes precedence. Assessing the client's respiratory rate is important but not as urgent as administering a bronchodilator to address the breathing difficulty.

2. A client is being discharged with a prescription for digoxin (Lanoxin). Which of the following instructions should the nurse include in the discharge teaching?

Correct answer: A

Rationale: The correct answer is A: 'Take your pulse daily before taking this medication.' It is essential for clients taking digoxin to monitor their pulse daily to detect bradycardia, a potential side effect. Choice B is incorrect because clients should never take an extra dose if a dose is missed; they should take the missed dose as soon as remembered unless it is close to the time for the next dose. Choice C is incorrect because digoxin is preferably taken with food to minimize gastrointestinal side effects. Choice D is incorrect because digoxin itself can cause low potassium levels, so avoiding potassium-rich foods is not necessary.

3. During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies?

Correct answer: D

Rationale: The correct answer is D: “I will replace any IV catheter when I suspect contamination during insertion.” This statement demonstrates an understanding of preventive strategies for IV infections. Suspecting and replacing any contaminated IV catheter during insertion is crucial to prevent infections and ensure patient safety. Choices A, B, and C are incorrect because leaving the IV catheter in place after completing antibiotics, reusing the same IV catheter, and disconnecting the IV infusion without proper precautions can increase the risk of infections. Therefore, option D is the best choice for preventing IV infections.

4. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?

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.

5. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.

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