the nurse assigns an unlicensed assistive personnel uap to feed a client who is at risk for aspiration what action should the nurse take to ensure saf
Logo

Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

2. The nurse is providing discharge instructions to a client who had a laparoscopic cholecystectomy. What should the nurse include in the teaching?

Correct answer: C

Rationale: The correct answer is C: 'Remove the bandages from the incision after 24 hours.' Prompt removal of bandages after 24 hours promotes proper wound healing and reduces the risk of infection. Choice A is incorrect because avoiding driving for 2 weeks may not be universally necessary post-cholecystectomy. Choice B is incorrect because while a low-fat diet is recommended after surgery, it is not directly related to incision care. Choice D is incorrect because while pain is common post-surgery, stating 'significant pain for the first week' may not apply to all patients, potentially causing unnecessary anxiety.

3. A client with a history of hypertension is prescribed lisinopril. Which potential side effect should the nurse monitor for?

Correct answer: C

Rationale: The correct answer is C: Persistent cough. Lisinopril is an ACE inhibitor commonly associated with a persistent dry cough as a side effect. This cough is thought to result from increased bradykinin levels. Choices A, B, and D are incorrect. Hypokalemia is not a common side effect of lisinopril; in fact, it may lead to hyperkalemia. Hyperglycemia is not a typical side effect of lisinopril use. Tachycardia is also not a common side effect associated with ACE inhibitors like lisinopril.

4. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?

Correct answer: C

Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.

5. A client with a history of seizure disorder who is receiving phenytoin (Dilantin) is being discharged. Which instruction should the nurse provide?

Correct answer: B

Rationale: The correct answer is to instruct the client to monitor drug levels regularly. This is crucial for phenytoin (Dilantin) to ensure that the medication levels are within the therapeutic range and to prevent toxicity. Choice A, taking the medication at bedtime, is not specifically required for phenytoin administration. Choice C, avoiding alcohol, is generally a good practice with medications but is not as critical as monitoring drug levels for phenytoin. Choice D, taking the medication at the same time every day, is important for consistency but does not address the specific monitoring needs of phenytoin.

Similar Questions

The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?
A client reports feeling isolated and lonely two weeks after the death of a spouse. What is the most appropriate nursing intervention?
A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?
When reconstituted, how many milligrams are in each milliliter of solution?
When providing care for a client receiving palliative care for terminal cancer, what should the nurse prioritize?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses