a nurse discovers a small paper fire in a trash can in a clients bathroom the client has been taken to safety and the alarm has been activatewhich of
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Nursing Elites

HESI LPN

HESI Fundamentals Practice Questions

1. A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is B: Obtain a class C fire extinguisher to extinguish the fire. Using a class C fire extinguisher is appropriate for electrical fires, which can include fires involving electrical equipment or appliances. In this scenario, a paper fire in a trash can in the client's bathroom could potentially involve electrical components, making a class C fire extinguisher the most suitable choice. Option A, opening the windows, may help with ventilation but does not address the fire directly. Option C, removing electrical equipment, is a precautionary measure but does not address the immediate fire hazard. Option D, placing wet towels along the base of the door, is a strategy to prevent smoke from entering the room but does not extinguish the fire.

2. The nurse is caring for a patient who has experienced a stroke causing total paralysis of the right side. To help maintain joint function and minimize the disability from contractures, passive range of motion (ROM) will be initiated. When should the nurse begin this therapy?

Correct answer: B

Rationale: Passive ROM exercises should begin as soon as the patient loses the ability to move the extremity or joint. Initiating passive ROM early helps prevent contractures and maintain joint function. Choice A is incorrect because delaying passive ROM until after the acute phase may lead to irreversible contractures. Choice C is not the best option as waiting until the patient enters the rehab unit delays crucial preventive measures. Choice D is incorrect as passive ROM should not be based on patient requests but on clinical indications and best practices.

3. The nurse is assessing a 17-year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?

Correct answer: C

Rationale: The correct answer is C, 'Decreased potassium.' Clients with bulimia often have decreased potassium levels due to frequent vomiting, which causes a loss of this essential electrolyte. This loss can lead to various complications such as cardiac arrhythmias. Option A, 'Increased serum glucose,' is not typically associated with bulimia. Option B, 'Decreased albumin,' is more related to malnutrition or liver disease rather than bulimia. Option D, 'Increased sodium retention,' is not a common finding in clients with bulimia; instead, they may experience electrolyte imbalances like hyponatremia due to purging behaviors.

4. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?

Correct answer: C

Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.

5. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

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