a nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks which of the following methods of assessment shoul
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HESI LPN

HESI Fundamentals Exam

1. A healthcare professional is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the healthcare professional use first?

Correct answer: A

Rationale: Inspection is the initial step in abdominal assessment as it allows the healthcare professional to visually observe any abnormalities or signs of bloating. Palpation, auscultation, and percussion are subsequent assessment techniques that follow inspection. Palpation involves feeling for tenderness, masses, or organ enlargement; auscultation is listening for bowel sounds; and percussion is used to assess the density of underlying tissues or detect the presence of fluid or air in the abdomen. In the context of a client reporting bloating, the first step should be visual inspection to gather initial information. Palpation, auscultation, and percussion come after inspection to provide a more comprehensive assessment.

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. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?

Correct answer: A

Rationale: Placing the wheelchair at a 45-degree angle to the bed is the correct technique for transferring a client who is unable to walk from bed to a wheelchair. This positioning facilitates a safer and easier transfer by providing more space for maneuvering and reducing the distance the client needs to be moved. Positioning the wheelchair parallel to the bed (Choice B) may make the transfer more challenging due to limited space and a longer distance to move the client. Placing the wheelchair in front of the bed (Choice C) may not provide an optimal angle for the transfer. Having the client stand and pivot into the wheelchair (Choice D) is not appropriate for a client who is unable to walk and could increase the risk of falls or injuries during the transfer.

4. The nurse has admitted a 4-year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?

Correct answer: B

Rationale: The correct answer is B. Rheumatic fever often follows a strep throat infection, which is why the nurse should suspect this association. Strep throat is caused by Group A Streptococcus bacteria, which can trigger an abnormal immune response leading to rheumatic fever. Choices A, C, and D are incorrect because chickenpox, ear infections, and fungal skin infections are not typically associated with rheumatic fever.

5. The LPN/LVN is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which observation indicates that the client is experiencing oxygen toxicity?

Correct answer: C

Rationale: The correct answer is 'C: Sore throat.' Oxygen toxicity can manifest with symptoms like a sore throat, cough, chest pain, difficulty breathing, and fatigue. However, a sore throat can be an early indicator of oxygen toxicity and should prompt immediate attention. Nasal congestion, cough, and fatigue are not specific indicators of oxygen toxicity but could be related to other factors in a client with COPD receiving oxygen therapy.

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