the patient is reporting an inability to clear nasal passages which action will the nurse take
Logo

Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?

Correct answer: A

Rationale: When a patient reports an inability to clear nasal passages, the appropriate action for the nurse to take is to use gentle suction to prevent tissue damage. Suctioning helps remove excess mucus or secretions without causing harm to the nasal tissues. Instructing the patient to blow their nose forcefully (Choice B) may exacerbate the issue and cause discomfort or injury. Placing a dry washcloth under the nose (Choice C) is not an effective intervention for clearing nasal passages. Inserting a cotton-tipped applicator into the back of the nose (Choice D) is not recommended as it can be invasive and may cause injury or discomfort to the patient.

2. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?

Correct answer: C

Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.

3. Which goal is most appropriate for a patient who has had a total hip replacement?

Correct answer: B

Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.

4. A client in a provider’s office tells the nurse that, 'I fast for several days each week to help control my weight.' The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that result from fasting puts her at risk for medication toxicity?

Correct answer: B

Rationale: Fasting can lead to an increased protein-binding response of medications. This can result in a higher concentration of bound medications in the bloodstream, potentially causing toxicity as the medications may not be readily available for metabolism or excretion. Choice A is incorrect because fasting typically doesn't increase medication metabolism. Choice C is incorrect as fasting usually decreases transit time through the intestines. Choice D is incorrect since fasting generally does not decrease medication excretion.

5. Which patient will lead the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?

Correct answer: B

Rationale: The correct answer is B because the nursing diagnosis of Impaired physical mobility is appropriate for a patient who has some limitations in mobility but is not completely immobile. Choice A is incorrect as a patient who is completely immobile would not have impaired physical mobility but rather no physical mobility at all. Choices C and D are also incorrect as they do not directly relate to the defining characteristics of Impaired physical mobility, which involve limitations in movement and physical activity.

Similar Questions

A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?
A client has restraints on each extremity. Which of the following assessments should the nurse perform first?
A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?
The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?

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