a nurse is screening several clients at a neighborhood health fair which of the following assessment findings is the priority for referral for further
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

2. 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.

3. A healthcare professional is supervising the logrolling of a patient. To which patient is the healthcare professional most likely providing care?

Correct answer: A

Rationale: Logrolling is a technique used to move a patient as a single unit to prevent twisting or bending of the spine. Patients who have undergone neck surgery require special care to ensure the spinal column remains in straight alignment to prevent further injury. Therefore, the correct answer is a patient with neck surgery. Choice B, a patient with hypostatic pneumonia, does not require logrolling, as it is a condition affecting the lungs, not the spine. Choice C, a patient with a total knee replacement, does not typically necessitate logrolling, as the procedure focuses on the knee joint, not the spine. Choice D, a patient with a stage IV pressure ulcer, requires wound care but does not necessarily involve logrolling unless the ulcer is located in a critical area that requires special handling.

4. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

5. When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?

Correct answer: A

Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.

Similar Questions

A healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
A nurse is preparing an education program for staff about advocacy. What information should the nurse include?
The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?
The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

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