a nurse is caring for a young adult at a college health cliniwhich of the following actions should the nurse take first
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Nursing Elites

HESI LPN

HESI Fundamentals Practice Questions

1. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: Assessing the client’s health risks is the priority as it provides essential information to guide subsequent care. By understanding the client’s health risks, the nurse can tailor health education and interventions, such as immunizations and lifestyle modifications, to address specific needs. Providing information about immunization against meningitis (Choice A) is important but should come after assessing health risks. Instructing the client to have a TB skin test every 2 years (Choice B) is relevant but not the initial step in care. Teaching about exercise recommendations (Choice D) is also essential but should follow the assessment of health risks.

2. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

Correct answer: A

Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.

3. A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?

Correct answer: B

Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.

4. To minimize the side effects of vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include?

Correct answer: C

Rationale: The correct answer is to include a diet high in fluids to help minimize the side effects of vincristine. High fluid intake is important in managing potential side effects such as constipation, which is a common issue associated with vincristine therapy. Options A, B, and D are incorrect. A diet low in fat or high in iron is not specifically indicated for managing vincristine side effects. Additionally, a diet low in residue is not directly related to addressing vincristine side effects.

5. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

Similar Questions

The nurse is having difficulty reading the healthcare provider's written order that was written right before the shift change. What action should be taken?
A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?
After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?
When documenting client care, which of the following abbreviations should be used?
A client appears upset about the IV catheter insertion but does not communicate it to the nurse after being informed about the prescribed IV fluids. Which of the following is an appropriate nursing response?

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