a nurse is evaluating a clients use of a cane which of the following actions should the nurse identify as an indication of correct use
Logo

Nursing Elites

HESI LPN

Practice HESI Fundamentals Exam

1. When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?

Correct answer: C

Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.

2. A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

Correct answer: D

Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.

3. The healthcare provider is caring for a 17-month-old with acetaminophen poisoning. Which lab reports should the healthcare provider review first?

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the toxic effects of the drug on the liver. Liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) are essential markers to assess liver function and damage. Monitoring these enzymes early is crucial to detect hepatotoxicity and guide further management. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red and white blood cell counts are not specific to assess liver damage in this context. Blood urea nitrogen and creatinine levels are primarily used to evaluate kidney function, which is not the primary concern in acetaminophen poisoning.

4. A client with heart failure and a new prescription for hydrochlorothiazide is receiving discharge teaching about safety considerations from a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C. Leaving a light on in the bathroom at night is important for an older adult with heart failure who is taking hydrochlorothiazide, a diuretic that can cause nocturia. This safety measure helps prevent falls during nighttime bathroom visits. Option A is incorrect because taking a hot bath before bed can increase the risk of falls due to potential dizziness. Option B does not directly relate to safety considerations but rather the timing of medication administration. Option D, weighing oneself once weekly, is important for monitoring fluid retention but does not address safety concerns related to nocturia and falls.

5. When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first?

Correct answer: B

Rationale: The correct first action for the LPN to take when a desired outcome is not achieved is to note which actions were not implemented. This step helps in identifying gaps in the plan of care and reasons for not achieving the desired outcome. Establishing a new nursing diagnosis (Choice A) is not the initial step when evaluating the plan of care. Adding additional nursing orders (Choice C) may not address the root cause of the unachieved outcome. Collaborating with the healthcare provider (Choice D) should come after identifying the gaps in the plan and reasons for the outcome not being met.

Similar Questions

A healthcare professional is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the professional assess for?
In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to
A healthcare professional in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. Which of the following findings should the healthcare professional identify as an indication that the client has an infection?
A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?
In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?

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