the nurse is preparing to lift and reposition a patient which action will the nurse take first
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Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. When preparing to lift and reposition a patient, which action should the nurse take first?

Correct answer: A

Rationale: The first action the nurse should take when preparing to lift and reposition a patient is to assess the patient's weight to determine the assistance needed. This step is crucial for the safety of both the patient and the nurse. Positioning a drawsheet under the patient (Choice B) is important for the comfort and safety during the repositioning process but should come after assessing the weight and assistance requirements. Delegating the task to a nursing assistive personnel (Choice C) can be considered once the assessment is complete and additional help is needed. Attempting to manually lift the patient alone before asking for assistance (Choice D) is unsafe and should never be done without first assessing the weight and determining the need for help.

2. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, what substance should the nurse suggest the parents give the child sips of?

Correct answer: B

Rationale: The correct answer is B: Water. Giving sips of water can help dilute the drain cleaner while waiting for emergency transport, which may help reduce the potential harm caused by the ingestion. Choices A, C, and D are incorrect because tea, milk, and soda can interact with the chemicals in the drain cleaner or increase the risk of vomiting, which is not recommended in this situation.

3. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment as she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Correct answer: D

Rationale: The correct course of action for the nurse is to determine which staff members have already been fitted for particulate filter masks before changing assignments. This ensures safety and compliance with infection control protocols. Option A is incorrect as wearing a standard face mask before being fitted for a filter mask does not address compliance with droplet precautions. Option B is incorrect because the priority is to ensure all staff members have appropriate equipment before providing care. Option C is incorrect as a standard mask may not offer sufficient protection when dealing with clients under droplet precautions.

4. Which assessment data reflects the need for nurses to include the problem, “Risk for falls,” in a client’s plan of care?

Correct answer: B

Rationale: The correct answer is B. The recent administration of opioid analgesics increases the risk for falls due to potential side effects such as sedation and dizziness. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk for falls. Choice C, stooped posture with an unsteady gait, may indicate an existing risk but does not directly reflect the need to include 'Risk for falls' in the care plan. Choice D, expressed feelings of depression, is important to address but is not directly associated with the risk for falls.

5. A parent is reviewing safety measures for an 8-month-old infant with a nurse. Which of the following statements by the parent indicates an understanding of safety for the infant?

Correct answer: A

Rationale: Choice A is correct because removing the crib gym prevents potential safety hazards such as choking or entrapment. Choices B, C, and D are incorrect as they pose risks to the infant's safety. A firm mattress is recommended for infants to reduce the risk of suffocation. Soft mattresses and fluffy pillows increase the risk of suffocation and Sudden Infant Death Syndrome (SIDS). Placing the baby's car seat on a table can lead to falls or other accidents.

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