a nurse is calculating a clients fluid intake over the past 8 hr which of the following should the nurse plan to document on the clients intake and ou
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HESI LPN

Practice HESI Fundamentals Exam

1. A healthcare professional is calculating a client's fluid intake over the past 8 hr. Which of the following should the healthcare professional plan to document on the client's intake and output record as 120 mL of fluid?

Correct answer: A

Rationale: Choice A, '8 oz of ice chips,' is the correct answer. 8 oz is equivalent to approximately 240 mL, and since 1 oz is roughly equal to 30 mL, 8 oz would be approximately 240 mL. Since the question specifies 120 mL of fluid, this option does not match. Choices C and D, '1 cup of broth,' do not equate to 120 mL. A standard cup is approximately 240 mL, which is double the amount mentioned in the question. Therefore, choice A is the most accurate representation of 120 mL of fluid intake.

2. A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse’s priority?

Correct answer: C

Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.

3. During assessment, what is a nurse monitoring when assessing body alignment?

Correct answer: A

Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.

4. A healthcare professional is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the healthcare professional uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the healthcare professional using when reviewing the medication information?

Correct answer: A

Rationale: The correct answer is A: Knowledge. In this scenario, the healthcare professional is utilizing knowledge by gathering and applying information about the medication. Choice B, Experience, is not the best option as the focus is on accessing information about the medication rather than personal experience. Choice C, Intuition, refers to a gut feeling or instinct, which is not evident in the scenario. Choice D, Competence, relates more to overall ability and proficiency rather than the specific act of seeking information.

5. A charge nurse is assigning tasks to a nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP?

Correct answer: D

Rationale: The correct answer is D because monitoring the color of a client's urinary output is a task that can be safely delegated to assistive personnel. This task involves basic observation and does not require specialized nursing knowledge or skills. Choice A is incorrect because reporting ABG results to the provider requires interpretation and critical thinking skills typically performed by a nurse. Choice B is incorrect as instructing a client about how to use an incentive spirometer involves educating and assessing the client, which is a nursing responsibility. Choice C is incorrect as administering enteral feeding to a client with a gastrostomy tube requires nursing expertise to ensure proper technique and monitoring for complications.

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