a nurse is caring for a client who has acute renal failure which of the following assessments provides the most accurate measure of the clients fluid
Logo

Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. A client has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Correct answer: A

Rationale: Daily weight is the most accurate measure of fluid status in a client with acute renal failure. Fluctuations in weight reflect changes in body fluid volume, including both fluid retention or loss. Intake and output, while important, may not always accurately reflect overall fluid status as it does not account for insensible losses. Urine specific gravity can provide information on urine concentration but does not offer a comprehensive assessment of overall fluid status. Peripheral edema, although a sign of fluid retention, is a more subjective assessment and may not always accurately reflect the client's fluid status like daily weight monitoring does.

2. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?

Correct answer: A

Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.

3. A client with a terminal illness is being educated by a healthcare provider about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the ED and I had difficulty breathing?”

Correct answer: C

Rationale: In the scenario described, the client has a living will that declines resuscitation. Therefore, if the client arrives at the emergency department with difficulty breathing, healthcare providers would consult the living will to understand the client's wishes. Providing comfort care, which may include oxygen therapy to alleviate symptoms, aligns with the client's preferences. Option A incorrectly suggests an intervention that goes against the client's wishes. Option B is incorrect because full resuscitation efforts are not in line with the client's choice to decline resuscitation. Option D is also incorrect as it does not consider the client's living will and the need to provide care according to the documented preferences of the client.

4. A healthcare professional is teaching about home safety with a client. Which of the following instructions should the healthcare professional include?

Correct answer: B

Rationale: The correct answer is to use electrical tape to secure extension cords next to baseboards on the floor. This practice helps prevent tripping and electrical hazards by keeping cords out of the way. Option A is incorrect as unplugging electronics should be done by holding the plug, not the cord itself. Option C is incorrect because when using a fire extinguisher, it should be aimed at the base of the flames, not at the top. Option D is not directly related to home safety teaching and may not be necessary for all clients, as it suggests an unnecessary change that may not improve safety.

5. What is the most suitable snack food for the LPN/LVN to offer a client with myasthenia gravis who is at risk for altered nutritional status?

Correct answer: A

Rationale: Chocolate pudding is the best snack food choice for a client with myasthenia gravis at risk for altered nutritional status due to its nutrient density and soft texture, which can be easier for clients with swallowing difficulties to consume. Graham crackers, sugar-free gelatin, and apple slices may not provide the same level of nutrient density or ease of consumption for these clients. Graham crackers and apple slices may also pose challenges for clients with swallowing difficulties, while sugar-free gelatin, although a good option for some clients, may not offer the same level of nutrition as chocolate pudding.

Similar Questions

The healthcare provider is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include...
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?
The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?
The patient is being taught about flossing and oral hygiene. What instruction will the nurse include in the teaching session?
A 3-year-old child has had multiple tooth extractions while under general anesthesia. The client returns from the post-anesthesia care unit crying but awake. Which approach is likely to be successful?

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