the nurse observes an uap positioning a newly admitted client who has a seizure disorder the client is supine and the uap is placing soft pillows alon
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Nursing Elites

HESI LPN

HESI Fundamentals Exam

1. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. Which action should the nurse implement?

Correct answer: A

Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.

2. A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and 'not feeling well.' The nurse notes warmth, edema, induration, and red streaking on the client’s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

Correct answer: D

Rationale: Discontinuing the infusion is the first step in addressing potential complications such as phlebitis or infection. It is crucial to prevent further infusion-related damage by stopping the source of the issue. Obtaining a specimen for culture (Choice A) can be considered later to identify the specific microorganism causing the infection. Applying a warm compress (Choice B) or administering analgesics (Choice C) may provide comfort but do not address the underlying issue of infection or phlebitis, which requires immediate intervention by discontinuing the infusion.

3. A healthcare provider is caring for a client who has a heart murmur. The healthcare provider is preparing to auscultate the pulmonary valve. Over which of the following locations should the healthcare provider place the bell of the stethoscope?

Correct answer: A

Rationale: The correct location to auscultate the pulmonary valve is the second intercostal space at the left sternal border. This area is where the pulmonary valve can best be heard due to its anatomical position. Choice B, the fifth intercostal space at the midclavicular line, is the location for auscultating the mitral valve. Choice C, the fourth intercostal space at the left sternal border, is the area for the tricuspid valve. Choice D, the fifth intercostal space at the left anterior axillary line, is the site for listening to the mitral valve as well. Therefore, option A is the correct choice for auscultating the pulmonary valve.

4. The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?

Correct answer: C

Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.

5. The client is receiving discharge instructions for warfarin (Coumadin). Which statement by the client indicates a need for further teaching?

Correct answer: A

Rationale: The correct answer is A. Clients taking warfarin need to be consistent with their vitamin K intake to maintain a balance in blood clotting. Avoiding foods high in vitamin K is essential as they can interfere with the medication's effectiveness. Choices B, C, and D are all correct statements regarding warfarin therapy. Regular blood testing to monitor INR levels ensures the medication is working effectively, taking the medication at the same time daily maintains a consistent level in the bloodstream, and using a soft toothbrush helps prevent gum bleeding due to warfarin's anticoagulant effects.

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