a nurse is performing passive range of motion rom and splinting on an at risk patient the absence of which finding will indicate goal achievement for
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Nursing Elites

HESI LPN

HESI Fundamentals Exam

1. During passive range of motion (ROM) and splinting, the absence of which finding will indicate goal achievement for these interventions?

Correct answer: D

Rationale: The correct answer is D: Joint contractures. When a healthcare provider performs passive ROM and splinting on a patient, the goal is to prevent joint contractures. Joint contractures result from immobility and can lead to permanent stiffness and decreased range of motion. Atelectasis (choice A) is a condition where there is a complete or partial collapse of the lung, commonly due to immobility, but not directly related to passive ROM or splinting. Renal calculi (choice B) are kidney stones and are not typically associated with ROM exercises. Pressure ulcers (choice C) result from prolonged pressure on the skin and are prevented by repositioning the patient, not specifically addressed by ROM and splinting exercises.

2. A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

Correct answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

3. Upon admission to the hospital, a client presents with decreased circulation in the left leg. What is the most important initial nursing action during the assessment?

Correct answer: B

Rationale: When a client is admitted with decreased circulation in the left leg, the most critical initial nursing action is to evaluate the pedal pulses. Pedal pulses provide essential information about the circulation status in the affected leg. Assessing the client's mobility (Choice A) is important but not as crucial as evaluating pedal pulses in this scenario. Monitoring skin temperature (Choice C) and checking for swelling (Choice D) are also relevant, but they are secondary to evaluating pedal pulses since the latter directly assesses the circulation in the affected limb.

4. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

5. A client is being taught about the use of an incentive spirometer. Which statement by the client indicates effective teaching?

Correct answer: A

Rationale: The correct answer is A because using the spirometer every hour while awake is an effective way to prevent respiratory complications. This frequency helps in maintaining lung function and preventing atelectasis. Choice B is incorrect because blowing too hard into the spirometer can lead to hyperventilation and dizziness, making choice C also incorrect. Choice D is wrong as waiting to use the spirometer only when feeling short of breath may not provide optimal lung expansion and can lead to respiratory issues.

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