a nurse is evaluating care of an immobilized patient which action will the nurse take
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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 client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

Correct answer: A

Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.

3. A nurse manager is preparing to review practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Correct answer: D

Rationale: The correct answer is D: Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. Options A, B, and C involve procedures that typically fall within the scope of other healthcare professionals. Inserting an implanted port is often performed by specialized nurses or physicians, closing a laceration with sutures is usually done by healthcare providers with specific training in wound care, and placing an endotracheal tube is a procedure commonly carried out by anesthesiologists or respiratory therapists.

4. When assessing a client's neurologic system, what should the nurse ask the client to close their eyes and identify?

Correct answer: B

Rationale: When a nurse asks a client to identify a number traced on the palm of the hand with their eyes closed, it assesses the client's ability to perceive touch sensations. This test specifically evaluates the tactile discrimination of the client. The other options do not test the client's ability to identify sensations accurately with eyes closed. Option A tests auditory perception, option C tests vibratory sense, and option D tests object recognition but not tactile discrimination, making them incorrect choices.

5. A client is on bed rest. Which of the following interventions should the nurse plan to implement?

Correct answer: A

Rationale: To prevent complications associated with prolonged bed rest, encouraging the client to perform antiembolic exercises every 2 hours is essential. These exercises help promote circulation and prevent blood clots. Instructing the client to cough and deep breathe every 4 hours is beneficial for respiratory function, but it is not as critical as antiembolic exercises. Repositioning the client every 4 hours helps prevent pressure ulcers and maintain skin integrity. Restricting fluid intake is not recommended, as hydration is important for overall health and well-being, especially for clients on bed rest.

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