a nurse is caring for a client who is postoperative when the nurse prepares to change her dressing she says every time you change my bandage it hurts
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HESI LPN

HESI Fundamentals Exam Test Bank

1. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

2. During preoperative teaching, a client in a surgeon’s office expresses intent to prepare advance directives before surgery. Which statement by the client indicates understanding of advance directives?

Correct answer: C

Rationale: The correct answer is C. This statement reflects the client's understanding of advance directives, as it indicates a specific preference regarding life-sustaining treatment. Advance directives enable individuals to outline their healthcare preferences, including decisions about treatments they wish to receive or avoid. Choice A mentions family members but doesn't address specific healthcare wishes; choice B focuses on the surgery rather than personal directives; choice D discusses doctor approval but lacks details about the directive itself.

3. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which instruction should the LPN/LVN reinforce to the client to help manage their condition?

Correct answer: B

Rationale: Practicing pursed-lip breathing is an essential technique to help manage COPD as it can improve oxygenation by promoting better gas exchange. This technique helps to keep the airways open longer during exhalation, preventing air trapping and improving breathing efficiency. Increasing fluid intake can help thin secretions, which is beneficial, but it is not the primary instruction for managing COPD. Avoiding physical activity is not recommended as it can lead to deconditioning and worsen dyspnea in COPD patients. Using a peak flow meter is more commonly associated with monitoring asthma rather than COPD, so it is not the most relevant instruction for managing COPD.

4. The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?

Correct answer: B

Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.

5. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

Similar Questions

After repositioning a client who reports shortness of breath, which of the following actions should the nurse take next?
A nurse questions a medication prescription as too extreme in light of the client’s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?
When admitting an older adult client who is Hispanic, which of the following cultural considerations should the nurse include when developing the plan of care?
Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?

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