a nurse is evaluating care of an immobilized patient which action will the nurse take
Logo

Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. When evaluating care of an immobilized patient, which action will the nurse take?

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

2. A healthcare provider is providing discharge teaching to a client about self-administering heparin.

Correct answer: A

Rationale: Heparin is typically administered in the abdomen for self-injection to avoid muscle tissue and for better absorption. The subcutaneous tissue in the abdomen provides a larger area for injection and is usually recommended for heparin administration. Administering heparin in the thigh, upper arm, or buttock may not be as effective or safe as the abdomen due to variations in absorption rates and potential risks associated with muscle injection.

3. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

Correct answer: A

Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.

4. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

5. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching?

Correct answer: C

Rationale: The correct answer is C. Protecting others from exposure when transporting a client with MRSA is crucial in preventing the spread of infection. This statement demonstrates understanding of infection control measures. Stating that MRSA is usually resistant to vancomycin (choice B) is incorrect; vancomycin is often effective against MRSA. Obtaining a specimen for culture and sensitivity after the first dose of an antimicrobial (choice A) is unnecessary and not indicated. Discontinuing antimicrobial therapy when the client is no longer febrile (choice D) is incorrect because antimicrobial therapy should be completed as prescribed to prevent the development of resistant strains.

Similar Questions

The nurse is caring for a client with cirrhosis of the liver. Which finding should the LPN/LVN report to the healthcare provider immediately?
The nurse is assessing a 17-year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?
While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?
In a client with liver cirrhosis, which symptom would be most concerning during assessment?
A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?

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