a nurse in a providers office is preparing to assess a clients skin as part of a comprehensive physical examination which of the following findings sh
Logo

Nursing Elites

HESI LPN

Fundamentals HESI

1. When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?

Correct answer: A

Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.

2. A client with diabetes mellitus is learning to self-administer insulin. Which action by the client indicates the need for further teaching?

Correct answer: B

Rationale: Drawing up insulin after warming the vial to room temperature indicates a need for further teaching, as insulin should be at room temperature for administration. Choice A is correct as rotating injection sites helps prevent lipodystrophy. Choice C is correct as pinching the skin helps ensure proper subcutaneous injection. Choice D is correct as injecting insulin at a 90-degree angle is the recommended technique for subcutaneous injections.

3. The nurse is providing discharge teaching to a client who has been prescribed warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D: 'I can take aspirin if I have a headache.' This statement indicates a need for further teaching because aspirin can increase the risk of bleeding in clients taking warfarin. Clients on warfarin therapy should avoid taking aspirin or other medications that increase the risk of bleeding. Choices A, B, and C are correct statements that show understanding of warfarin therapy, such as the importance of avoiding foods high in vitamin K, taking medication consistently, and using a soft toothbrush to prevent gum bleeding.

4. A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?

Correct answer: D

Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.

5. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

Similar Questions

During assessment, what is a nurse monitoring when assessing body alignment?
An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?
A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?
To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?
While documenting in a client’s medical record, which of the following entries should the nurse record?

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