a nurse is preparing to insert an iv catheter for an adult client which of the following actions should the nurse take
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.

2. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

Correct answer: A

Rationale: The correct statement the nurse should include in the teaching is to 'Sit on the toilet 30 minutes after eating a meal.' This advice can help establish a regular bowel routine and improve bowel movement. Option B, 'Increase your fluid intake to help with bowel movements,' while important, is not specific to the time after eating and does not directly address the need for establishing a routine. Option C, 'Exercise regularly to improve bowel function,' is also important but does not address the timing of bowel movements. Option D, 'Consume more high-fiber foods to prevent constipation,' is beneficial for preventing constipation but does not address the timing aspect related to bowel movements.

3. A client with a body mass index (BMI) of 30 is seeking advice on the initial approach to a weight loss plan. What action should the nurse recommend?

Correct answer: C

Rationale: Keeping a food diary is an essential practice when starting a weight loss plan as it helps in tracking calorie intake, identifying eating patterns, and making informed decisions about dietary changes. Planning meals with low carbohydrates and high protein (Choice A) can be beneficial for some individuals, but keeping a food diary is more foundational. Engaging in strenuous daily activity (Choice B) may not be sustainable for everyone and could lead to burnout or injuries. Participating in a group exercise class (Choice D) is beneficial for fitness but may not address dietary habits, which are crucial for weight loss.

4. The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?

Correct answer: C

Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.

5. Which toy is most appropriate for an 18-month-old child?

Correct answer: A

Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.

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