a nurse is caring for several clients who are receiving o2 therapy which client should the nurse assess most frequently for manifestations of oxygen t
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A healthcare provider is caring for several clients who are receiving oxygen therapy. Which client should the provider assess most frequently for manifestations of oxygen toxicity?

Correct answer: A

Rationale: When a client is receiving 100% oxygen via a partial rebreathing mask, there is a higher risk for oxygen toxicity due to the higher concentration of oxygen delivered. This client should be assessed most frequently for manifestations of oxygen toxicity. Choices B, C, and D are less likely to result in oxygen toxicity compared to 100% oxygen delivery via a partial rebreathing mask.

2. A client scheduled for abdominal surgery reports being worried. Which of the following actions should the nurse take?

Correct answer: A

Rationale: Offering relaxation techniques addresses the client's immediate concern by providing a proactive approach to managing anxiety. It shows empathy and offers a practical solution. Requesting a social worker for meditation (Choice B) may not be the most direct response to the client's immediate worry. Attempting biofeedback (Choice C) may not be suitable without the client's interest or consent. Telling the client to think of something else (Choice D) dismisses the client's feelings and does not provide constructive support.

3. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

Correct answer: A

Rationale: The correct answer is A: 'Patient is lying on side.' In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Choice B, 'Patient is lying on back,' is incorrect as it describes a supine position. Choice C, 'Patient is lying semiprone,' is incorrect as it refers to a position where the patient is partially lying on the abdomen. Choice D, 'Patient is lying on abdomen,' is incorrect as it describes a prone position where the patient is lying face down.

4. A client needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

Correct answer: A

Rationale: Cheddar cheese is the correct answer as it is a good source of complete protein that contains all essential amino acids required for maintaining a positive nitrogen balance for wound healing. Complete proteins provide all essential amino acids needed by the body. White rice, apples, and green beans do not offer complete proteins like cheddar cheese, making them inadequate choices for this purpose.

5. Which anatomical location is associated with the deep tendon reflex known as the patellar reflex?

Correct answer: A

Rationale: The patellar reflex, also called the knee-jerk reflex, is elicited by tapping the patellar tendon just below the patella. This reflex involves the quadriceps muscle and the femoral nerve. The correct answer is 'A: Knee picture' because the patellar reflex is associated with the knee joint. Choices B, C, and D are incorrect as they do not correspond to the anatomical location involved in the patellar reflex.

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