a nurse is assessing the body alignment of a standing patient which finding will the nurse report as normal
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

2. When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?

Correct answer: A

Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.

3. A client recovering from lung cancer is advised to resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Correct answer: A

Rationale: The correct answer is A: Washing dishes. Washing dishes is a lower-intensity activity that is suitable for a client recovering from lung cancer. This activity does not require significant physical exertion and allows the client to engage in a manageable task while still following the provider's instructions for lower-intensity activities. Choices B, C, and D involve more physical effort and may not be appropriate for a client recovering from lung cancer, as they require more energy and physical strain, which could hinder the recovery process.

4. While being educated by a nurse, an assistive personnel (AP) is learning about proper hand hygiene. Which statement made by the AP indicates a good understanding of the teaching?

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates an understanding that soap and water should be used when hands are visibly dirty or when dealing with specific pathogens. Choice A is incorrect because it suggests the use of soap and water over alcohol-based hand rub without specifying the circumstances. Choice B is incorrect as it implies that using alcohol-based hand rub after using the restroom is always suitable. Choice D is incorrect because it states that hand rub is always enough, which is not true when hands are visibly soiled or when specific pathogens are present.

5. When ambulating a frail, older adult client, the nurse should:

Correct answer: A

Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.

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