a nurse is teaching an adult client how to administer ear drops which of the following statements should the nurse identify as an indication that the
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

Correct answer: B

Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.

2. A healthcare professional is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the healthcare professional take?

Correct answer: A

Rationale: When an irregular pulse is detected, it is essential to count the apical pulse rate for a full minute to accurately determine the rhythm. This ensures a comprehensive assessment and helps in identifying any potential issues or abnormalities. Rechecking the pulse at the same site after 5 minutes (Choice B) may not provide an immediate understanding of the irregularity. Measuring the client's blood pressure (Choice C) is important but not directly related to addressing the irregular pulse. Recording the irregularity and continuing with other vital signs (Choice D) may overlook a potentially serious cardiac issue that requires immediate attention.

3. To evaluate a client's understanding of self-administering insulin within the psychomotor domain of learning, what action should the instructor take?

Correct answer: A

Rationale: Having the client demonstrate the procedure is the most appropriate action to evaluate understanding within the psychomotor domain of learning. This allows the instructor to assess the client's ability to perform the skill, which is a key aspect of this domain. Choice B, explaining the procedure again, focuses on the cognitive domain rather than the psychomotor domain. Choice C, asking the client to describe the procedure, pertains more to the verbal or cognitive domain of learning. Choice D, observing the client watching a video on the procedure, does not directly assess the client's ability to perform the skill in the psychomotor domain.

4. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

5. A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to:

Correct answer: A

Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.

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