the nurse is caring for a client with a peripheral intravenous iv line that has infiltratewhat is the most appropriate initial action for the lpnlvn t
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. The healthcare professional is caring for a client with a peripheral intravenous (IV) line that has infiltrated. What is the most appropriate initial action for the healthcare professional to take?

Correct answer: B

Rationale: The correct initial action when an IV line infiltrates is to discontinue the IV and restart it in another site. This is crucial to prevent complications such as tissue damage, phlebitis, and infection that can result from the infiltration. Applying a warm compress (Choice A) is not recommended as it can exacerbate the tissue damage caused by the infiltration. Aspirating the IV line and flushing it with normal saline (Choice C) is not appropriate for an infiltrated IV line as it does not address the main issue of infiltration. While notifying the healthcare provider (Choice D) is important, the immediate priority is to discontinue the infiltrated IV to prevent further harm and ensure proper delivery of fluids or medications.

2. A community health nurse is caring for a group of families. The nurse should identify which of the following families is experiencing a maturational loss?

Correct answer: D

Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.

3. The healthcare provider is observing the way a patient walks. Which aspect is the healthcare provider assessing?

Correct answer: D

Rationale: When assessing the way a patient walks, the healthcare provider is evaluating the gait, which refers to a particular manner or style of walking. Body alignment pertains to the positioning of body parts in relation to one another, range of motion refers to the extent of movement of a joint, and activity tolerance relates to the ability to endure physical activities. In this scenario, observing the patient's walking pattern specifically focuses on gait assessment.

4. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia?

Correct answer: A

Rationale: The correct answer is A. Nasogastric suctioning can lead to hypovolemia due to the loss of gastric fluids. Chronic constipation and syndrome of inappropriate antidiuretic hormone (SIADH) are not typically associated with hypovolemia. A toxic dose of sodium bicarbonate antacids may lead to metabolic alkalosis, not hypovolemia.

5. 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.

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