the patient is reporting an inability to clear nasal passages which action will the nurse take
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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. A client asks a nurse about the purpose of advance directives.

Correct answer: A

Rationale: The correct answer is A: Advance directives serve to indicate the forms of medical treatment a client wishes to receive or decline in the event they are unable to communicate their preferences. This legal document allows individuals to make decisions about their future healthcare. Choice B is incorrect as advance directives do not specify the client's preferred hospital for treatment. Choice C is incorrect as advance directives do not determine the client's daily medication schedule; this is typically addressed in a medication administration record. Choice D is incorrect as advance directives do not outline the client's financial status and insurance coverage, but rather focus on healthcare treatment preferences.

3. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area?

Correct answer: B

Rationale: In providing a complete bed bath using a bag bath for an unconscious patient, the nurse should follow a specific order. The correct sequence is as follows: Neck, shoulders, and chest; Both arms, both hands, web spaces, and axilla; Abdomen and then groin/perineum; Right leg, right foot, and web spaces; Left leg, left foot, and web spaces; Back of neck, back, and then buttocks. Choice A is incorrect as it does not follow the correct sequence for a bed bath. Choice C is incorrect as it focuses on the lower extremities before addressing the upper body. Choice D is incorrect as it starts with the back of the patient instead of the upper body areas first.

4. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?

Correct answer: A

Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.

5. An adult client is found to be unresponsive during morning rounds. After checking for responsiveness and calling for help, what should the nurse do next?

Correct answer: D

Rationale: After confirming unresponsiveness and calling for help, the next step in basic life support is to open the client's airway. This ensures that the airway is clear and allows for effective ventilation. Checking the carotid pulse is not necessary at this stage as airway management takes precedence. Delivering abdominal thrusts is not indicated for an unresponsive client as it is for conscious choking individuals. Giving rescue breaths should only be done after ensuring the airway is open to allow for effective ventilation.

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