a nurse is planning care for a client who has a prescription for knee length anti embolic stockings which of the following actions should the nurse ta
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

2. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.

3. What is the first step a healthcare professional should take when preparing to provide tracheostomy care?

Correct answer: A

Rationale: Performing hand hygiene is the initial step a healthcare professional should take when preparing to provide tracheostomy care. This step is crucial to prevent the transmission of pathogens and reduce the risk of infection to the client. By cleansing the hands, the healthcare professional ensures patient safety. While gathering equipment, explaining the procedure, and assessing the client are essential components of tracheostomy care, they should occur after performing hand hygiene to maintain aseptic technique and minimize the risk of introducing harmful microorganisms to the client.

4. During an assessment, a healthcare professional is evaluating a client who has been on bed rest for the past month. Which of the following findings should the healthcare professional identify as an indication that the client has developed thrombophlebitis?

Correct answer: C

Rationale: Calf swelling, redness, and tenderness are classic signs of thrombophlebitis. The swelling occurs due to the formation of a blood clot in the deep veins of the calf, leading to inflammation and potential obstruction of blood flow. Bladder distention (Choice A) is more indicative of urinary retention, decreased blood pressure (Choice B) can be seen in conditions like shock, and diminished bowel sounds (Choice D) may suggest gastrointestinal issues, none of which are directly related to thrombophlebitis.

5. A healthcare professional reviewing a client’s health record notes a new prescription for lisinopril 10 mg PO once daily. The healthcare professional should identify this as which of the following types of prescription?

Correct answer: C

Rationale: A prescription for once-daily medication is considered routine as it is meant for regular, daily administration to maintain therapeutic levels in the body. Single prescriptions are for one-time use only. Stat prescriptions are for immediate administration in urgent situations, while now prescriptions are also for immediate use but may have varying levels of urgency depending on the patient's condition. In this case, since the prescription is for once daily use, it falls under the category of routine prescription.

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