a nurse is planning to use non pharmacological pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago
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Nursing Elites

HESI LPN

HESI Fundamentals Exam

1. A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?

Correct answer: C

Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.

2. A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?

Correct answer: C

Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.

3. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

Correct answer: A

Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.

4. A client with a history of alcoholism is admitted with confusion and ataxia. The LPN/LVN recognizes that these symptoms may be related to a deficiency in which vitamin?

Correct answer: D

Rationale: The correct answer is Vitamin B1 (Thiamine). Vitamin B1 deficiency, also known as Thiamine deficiency, is common in clients with a history of alcoholism. Thiamine is essential for proper brain function, and its deficiency can lead to neurological symptoms such as confusion and ataxia. Vitamin A, C, and D deficiencies do not typically present with confusion and ataxia in the context of alcoholism. Vitamin A deficiency mainly affects vision, Vitamin C deficiency leads to scurvy with symptoms like bleeding gums, and Vitamin D deficiency is associated with bone disorders. Therefore, they are not the correct choices in this scenario.

5. 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.

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