a nurse is talking with an adolescent who is having difficulty dealing with several issues which of the following issues should the nurse identify as
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

2. A client with a tracheostomy collar has a decrease in heart rate and oxygen saturation during tracheal suctioning. Which of the following actions should the nurse take?

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to discontinue suctioning. Suctioning should be stopped immediately to prevent further decrease in heart rate and oxygen saturation. Elevating the head of the bed may help with oxygenation, but the priority is to stop the suctioning procedure. Removing the inner cannula or irrigating the stoma are not appropriate actions and could worsen the client's condition.

3. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should:

Correct answer: A

Rationale: Weighing the client upon rising is the correct approach when caring for a client with fluid volume excess. Weighing the client in the morning upon rising provides a consistent and accurate measure of weight, as it helps to eliminate the influence of daily fluctuations that can occur throughout the day. Weighing at different times of the day (choice B) may lead to inconsistent measurements due to variations in food intake, hydration status, and other factors. Weighing the client after meals (choice C) can also lead to inaccurate readings as food and fluid intake can affect weight. Weighing the client weekly (choice D) is not frequent enough to monitor changes in weight accurately for a client with fluid volume excess.

4. A healthcare professional is assessing a client’s extraocular eye movements. Which of the following should the professional do?

Correct answer: A

Rationale: Instructing the client to follow a finger through the six cardinal positions of gaze is the correct action when assessing extraocular eye movements. This technique assesses the movement of the eyes in all directions and helps to test cranial nerves 3, 4, and 6, which control eye movements. Choice B is incorrect as the distance mentioned is not relevant for assessing extraocular eye movements. Choice C is incorrect as both eyes need to be assessed independently. Choice D is incorrect as positioning the client 6.1 m (20 feet) away from the Snellen chart is related to visual acuity testing, not extraocular eye movements.

5. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements?

Correct answer: B

Rationale: A fracture near the epiphysis can result in retarded bone growth, so this should be communicated to the parents.

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