a nurse is providing preoperative education for a client who will undergo a mastectomy the next day which of the following statements should the nurse
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Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. During preoperative education, a nurse should assess a client's readiness to learn before a mastectomy. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

Correct answer: C

Rationale: The correct answer is C. Asking about the duration of the surgery indicates readiness to learn about the procedure. This question shows that the client is actively seeking information about the surgical process, demonstrating readiness to learn. Choices A, B, and D reflect concerns, specific requests, or statements unrelated to the learning process. They do not directly indicate readiness to absorb information about the upcoming mastectomy.

2. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Correct answer: A

Rationale: In this scenario, the nurse should assign the task of assisting the client with a partial bed bath to an assistive personnel (AP). APs are trained to provide basic care tasks like hygiene assistance. Options B, C, and D involve more complex tasks such as measuring BP, using a communication board for speech-impaired clients, and feeding, which require nursing judgment and skills beyond basic care. Therefore, these tasks should be performed by licensed nursing staff who can assess, communicate effectively, and address the specific medical and safety needs of the client.

3. During an admission assessment, a nurse is documenting a client's medication. Which of the following actions should the nurse take?

Correct answer: C

Rationale: During an admission assessment, compiling a list of the client's current medications is crucial for accurate documentation and planning. This information helps prevent medication errors, identify potential interactions, and ensure continuity of care. While counseling the client on medication adherence (Choice A) is important, it is not the primary action when documenting medications. Assessing the client for medication reactions (Choice B) is relevant for monitoring side effects but not the immediate focus during documentation. Evaluating the client's understanding of medications (Choice D) is essential for education but does not address the immediate need for compiling a list of current medications.

4. A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?

Correct answer: C

Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.

5. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Correct answer: B

Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.

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