a nurse is collecting data from a client who is receiving iv therapy and reports pain in the arm chills and not feeling well the nurse notes warmth ed
Logo

Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well.' The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

Correct answer: D

Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.

2. The nurse is caring for a client who is post-operative following a cholecystectomy. Which assessment finding would require immediate intervention?

Correct answer: D

Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention, such as ensuring hemostasis and preventing further complications. Absent bowel sounds are common in the immediate post-operative period and may not require immediate intervention unless accompanied by other symptoms. A pain level of 8/10 can be managed with appropriate pain medication and is not typically considered an immediate priority unless other indications suggest complications. A temperature of 100.4°F is slightly elevated but may not be a cause for immediate concern unless it is associated with other signs of infection or distress that would warrant urgent attention.

3. A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?

Correct answer: C

Rationale: The correct answer is C. It is an ethical dilemma when the family of a client with a terminal illness asks healthcare providers not to inform the client of their diagnosis. This situation poses a conflict between respecting the client's right to know the truth about their condition (autonomy and truth-telling principles) and honoring the family's wishes. Choices A, B, and D do not present ethical dilemmas. Choice A involves professional accountability and responsibility, Choice B involves a client's personal preference, and Choice D involves financial challenges.

4. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

5. Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?

Correct answer: D

Rationale: Choice D is the correct answer because having the 4-year-old help feed the four-month-old a bottle in the kitchen while the mother makes supper shows supervision of the infant by the older child in a safe environment. This choice indicates that the mother understands safety precautions by involving the older child in a caregiving task under her supervision. Choices A, B, and C are incorrect because they involve unsafe practices such as placing the infant on the floor unsupervised, positioning the infant car seat in the front seat, and not providing direct supervision of the children during naptimes.

Similar Questions

The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?
A client is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
A client with pneumonia is receiving antibiotic therapy. Which finding indicates that the treatment is effective?
The client is learning about lifestyle changes to manage hypertension. Which statement by the client requires further teaching?

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