the patient has been diagnosed with diabetes when admitted the patient is unkempt and is in need of a bath and foot care when questioned about hygiene
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HESI LPN

HESI Fundamentals Test Bank

1. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?

Correct answer: C

Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.

2. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

Correct answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

3. A healthcare professional is reviewing a client's fluid and electrolyte status. Which of the following findings should the healthcare professional report to the provider?

Correct answer: D

Rationale: The correct answer is D. A potassium level of 5.4 mEq/L is above the expected reference range, indicating hyperkalemia. Hyperkalemia can lead to serious complications such as dysrhythmias, making it important for the healthcare professional to report this finding to the provider for further evaluation and intervention. Choices A, B, and C fall within normal ranges and do not pose an immediate risk to the client's health, so they would not warrant immediate reporting to the provider. Elevated BUN or creatinine levels may indicate kidney dysfunction, while a sodium level of 143 mEq/L falls within the normal range for adults and does not typically require urgent intervention.

4. After performing foot care, the nurse checks the medical record and discovers that the patient has a disorder on the sole of the foot caused by a virus. Which condition did the nurse most likely observe?

Correct answer: C

Rationale: The nurse most likely observed plantar warts, which appear on the sole of the foot and are caused by the papillomavirus. Corns (Choice A) and calluses (Choice B) are areas of thickened skin caused by pressure or friction and are not typically associated with viruses. Athlete's foot (Choice D) is a fungal infection that usually affects the skin between the toes and is not caused by a virus like plantar warts.

5. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct intervention for an employee exposed to an unknown dry chemical is to brush off the chemical from the skin and clothing. This helps prevent further skin contact before irrigation can be done. Irrigating the affected area with running water is crucial after brushing off the chemical to minimize the exposure. Washing the affected area with antibacterial soap is not appropriate for chemical burns, as soap can react with certain chemicals and worsen the situation. Leaving the clothing in place until emergency personnel arrive may allow the chemical to continue to harm the skin and should be avoided.

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