a nurse is admitting a client who has decreased circulation in his left leg which of the following actions should the nurse take first
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HESI LPN

HESI Fundamentals 2023 Quizlet

1. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

2. While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to initiate contact precautions. MRSA (Methicillin-resistant Staphylococcus aureus) is a highly contagious bacterium that spreads through direct contact. Contact precautions involve wearing gloves and gowns to prevent the spread of infection to other patients or healthcare workers. Force-feeding oral fluids, requesting a nutrition consult, or limiting visitors to immediate family only are not the most appropriate actions in this scenario. These actions do not directly address the need to prevent the spread of MRSA, which is crucial in a healthcare setting.

3. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?

Correct answer: D

Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.

4. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?

Correct answer: D

Rationale: The correct answer is D. When taking isoniazid, alcohol consumption should be avoided as it can increase the risk of liver damage, potentially leading to drug-induced hepatitis. Choices A, B, and C are incorrect. Prolonged use of isoniazid does not typically cause dark concentrated urine; it is not necessary to take the medication on an empty stomach for optimal absorption; and it is not recommended to take isoniazid with aluminum hydroxide to minimize GI upset.

5. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

Correct answer: A

Rationale: The nurse should prioritize seeing the client who has new onset dyspnea 24 hours after a total hip arthroplasty first. This sudden dyspnea could indicate a serious complication like a pulmonary embolism, which requires immediate assessment and intervention. Acute abdominal pain, a UTI with a low-grade fever, and pneumonia with an oxygen saturation of 96% are important concerns but are not as immediately life-threatening as potential pulmonary embolism indicated by sudden dyspnea postoperatively.

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