a community health nurse is preparing a campaign about seasonal influenzwhich of the following plans should the nurse include as a secondary preventio
Logo

Nursing Elites

HESI LPN

HESI Fundamentals 2023 Quizlet

1. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention?

Correct answer: A

Rationale: The correct answer is A. Secondary prevention aims to detect and address health issues early. Screening older adults in nursing care facilities for early influenza manifestations is an example of secondary prevention by identifying cases at an early stage. Choice B, promoting hand hygiene, is a form of primary prevention that aims to prevent the occurrence of influenza. Choice C, administering influenza vaccinations, is a form of primary prevention as well, focusing on preventing the disease before it occurs. Choice D, educating about healthy lifestyle choices, is more related to health promotion and primary prevention rather than secondary prevention.

2. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should:

Correct answer: A

Rationale: Weighing the client upon rising is the correct approach when caring for a client with fluid volume excess. Weighing the client in the morning upon rising provides a consistent and accurate measure of weight, as it helps to eliminate the influence of daily fluctuations that can occur throughout the day. Weighing at different times of the day (choice B) may lead to inconsistent measurements due to variations in food intake, hydration status, and other factors. Weighing the client after meals (choice C) can also lead to inaccurate readings as food and fluid intake can affect weight. Weighing the client weekly (choice D) is not frequent enough to monitor changes in weight accurately for a client with fluid volume excess.

3. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?

Correct answer: B

Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.

4. While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

Correct answer: A

Rationale: After completing the task, the nurse should remove the gloves carefully and follow with hand hygiene. This practice is crucial to prevent the transmission of any potential pathogens, maintain cleanliness, and reduce the risk of infection. Changing gloves and continuing without proper hand hygiene may lead to contamination. Washing hands immediately without removing gloves is not recommended as it does not ensure thorough hand hygiene. Reporting the incident to the supervisor should be done if there are specific protocols in place for such incidents, but immediate hand hygiene is the priority in this scenario to ensure patient and nurse safety.

5. An assistive personnel tells the nurse, 'I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?' The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is:

Correct answer: B

Rationale: Using a regular blood pressure cuff on a morbidly obese client will lead to a falsely high blood pressure reading. This occurs because the cuff is not appropriately sized for the client's arm circumference, resulting in increased pressure on the artery and an inaccurate high reading. Choice A is incorrect because the reading will be falsely high, not low. Choice C is incorrect as the reading will not be accurate with an incorrectly sized cuff. Choice D is incorrect because the reading will be affected by using the wrong cuff size.

Similar Questions

The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
A client is scheduled for a total laryngectomy. Which of the following interventions is the priority for the nurse?
A healthcare professional is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the healthcare professional include?
A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses