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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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 healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?

Correct answer: C

Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.

3. When caring for a client with a tracheostomy, which of the following actions should the nurse take?

Correct answer: A

Rationale: When caring for a client with a tracheostomy, the nurse should clean the skin around the stoma with normal saline to prevent infection and ensure cleanliness. This action helps in maintaining skin integrity and preventing skin breakdown. Securing the tracheostomy ties with two fingers' width underneath is essential to allow for proper fit, prevent skin irritation, and ensure the ties are not too tight. Soaking the outer cannula in warm tap water is not recommended as it can lead to contamination and is not a standard practice. Using a cotton tip applicator to clean the inside of the inner cannula is discouraged as it can leave fibers behind, increasing the risk of aspiration and respiratory complications.

4. A healthcare professional is reviewing a client's health record and notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

Correct answer: C

Rationale: A routine prescription, such as lisinopril 10 mg PO once daily, is administered on a regular schedule with or without a termination date. It is a standard, ongoing prescription for maintenance therapy. Choice A, 'Single,' would typically refer to a one-time prescription. Choice B, 'Stat,' is used for prescriptions that are needed immediately or in emergency situations. Choice D, 'Now,' is not a common prescription type designation and is not applicable in this context.

5. The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

Correct answer: B

Rationale: The correct answer is B, a lactating woman nursing her 3-day-old infant. During lactation, women have increased nutritional needs, including protein, to support milk production for their infants. Protein is essential for proper growth and development. While choice A, a college-age track runner with a sprained ankle, may require protein for tissue repair, the lactating woman's need is greater due to the demands of breastfeeding. Choice C, a school-aged child with Type 2 diabetes, may have specific dietary considerations related to diabetes management but does not necessarily require additional protein intake compared to a lactating woman. Choice D, an elderly man being treated for a peptic ulcer, may need protein for wound healing, but the nutritional need for a lactating woman is higher to support her infant's growth.

Similar Questions

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A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?
A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials?
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