a patient has scaling of the scalp which term will the nurse use to report this finding to the oncoming staff
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff?

Correct answer: A

Rationale: The correct term the nurse will use to report scaling of the scalp is 'Dandruff.' Dandruff is characterized by scaling of the scalp that is often accompanied by itching. Choice B, 'Alopecia,' refers to hair loss, not scaling. Choice C, 'Pediculosis,' is the infestation of lice, not scaling. Choice D, 'Xerostomia,' pertains to dry mouth, which is unrelated to the described symptom of scaling of the scalp.

2. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement?

Correct answer: A

Rationale: The correct action for the LPN/LVN to implement is to give an around-the-clock schedule for administration of analgesics. This approach helps maintain consistent pain management by providing the medication regularly, preventing the pain from becoming severe. Choice B is incorrect because waiting for severe pain before administering the analgesic may lead to uncontrolled pain levels. Choice C is inappropriate as the goal of pain management in hospice care is to provide comfort without unnecessary sedation. Choice D is also incorrect as offering a medication-free period may result in inadequate pain control for the client.

3. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which of the following laboratory values would be most concerning?

Correct answer: A

Rationale: An INR of 1.5 is below the therapeutic range for clients on anticoagulation therapy, increasing the risk of clot formation. A lower INR indicates inadequate anticoagulation, which can lead to thrombus formation and potential complications such as progression or recurrence of deep vein thrombosis. Platelet count, hemoglobin level, and aPTT are important parameters to monitor in a client with DVT. However, in this scenario, the most concerning value is the suboptimal INR level because it signifies a lack of anticoagulation effectiveness and poses a higher risk of clotting issues.

4. A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.

5. A client with an NG tube is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct answer is to tell the client to keep the head of the bed elevated at least 30°. Elevating the head of the bed prevents aspiration of the enteral formula, which is a priority in caring for a client with an NG tube. This action helps in reducing the risk of complications such as pneumonia. Choices A, C, and D are incorrect. While rinsing the feeding bag, ensuring the enteral formula temperature, and maintaining cleanliness are important aspects of enteral feeding care, the priority is to prevent aspiration by keeping the head of the bed elevated. These actions can be implemented after ensuring the client's safety by maintaining the correct bed position.

Similar Questions

A healthcare professional is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the healthcare professional adjust the manual IV infusion to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client’s medication administration record, which of the following medications should be administered?
A client with chronic kidney disease is receiving epoetin alfa (Epogen). Which laboratory value should the nurse monitor to determine the effectiveness of this medication?
A healthcare professional is reviewing the medical record of a client who has hypocalcemia. The healthcare professional should identify which of the following findings as a risk factor for the development of this electrolyte imbalance?
An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?

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