when entering the room of an adult male the nurse finds that the client is very anxious before providing care what action should the nurse take
Logo

Nursing Elites

HESI LPN

HESI Fundamentals 2023 Quizlet

1. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take?

Correct answer: D

Rationale: Re-assessing the client's situation before providing care is the most appropriate action in this scenario. By re-evaluating the client, the nurse can better understand the cause of the anxiety and tailor the care accordingly. Diverting the client's attention (Choice A) may not address the underlying issue causing anxiety. Calling for additional help (Choice B) is not the initial step required unless there is an urgent need. Documenting the planned action (Choice C) should come after reassessing the client to ensure accuracy and relevance.

2. A healthcare provider is assessing a client's ability to balance. Which of the following actions is appropriate when the healthcare provider conducts a Romberg test?

Correct answer: C

Rationale: The Romberg test is a neurological test that assesses proprioception and balance. To perform this test, the client is asked to stand with their feet together and arms at their sides while closing their eyes. By removing visual input, the test challenges the vestibular and proprioceptive systems. Choices A, B, and D are incorrect because they do not align with the proper procedure for conducting the Romberg test. Extending arms in front, walking heel to toe, or placing hands on hips are not part of the Romberg test protocol and may introduce variables that could affect the assessment of balance.

3. A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct answer is B: Obtain a class C fire extinguisher to extinguish the fire. Using a class C fire extinguisher is appropriate for electrical fires, which can include fires involving electrical equipment or appliances. In this scenario, a paper fire in a trash can in the client's bathroom could potentially involve electrical components, making a class C fire extinguisher the most suitable choice. Option A, opening the windows, may help with ventilation but does not address the fire directly. Option C, removing electrical equipment, is a precautionary measure but does not address the immediate fire hazard. Option D, placing wet towels along the base of the door, is a strategy to prevent smoke from entering the room but does not extinguish the fire.

4. A client with osteoporosis is prescribed alendronate (Fosamax). What instruction should the LPN/LVN provide to the client?

Correct answer: A

Rationale: The correct instruction for a client prescribed alendronate (Fosamax) is to take the medication with a full glass of water. Alendronate can cause irritation to the esophagus, so it is important to take it with a full glass of water and remain upright for at least 30 minutes after taking the medication to help prevent this irritation. Taking the medication at bedtime (choice B) may increase the risk of esophageal irritation as lying down can allow the medication to remain in the esophagus longer. Taking the medication with food (choice C) or on an empty stomach (choice D) can also interfere with the absorption of alendronate, reducing its effectiveness in treating osteoporosis.

5. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?

Correct answer: D

Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.

Similar Questions

The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?
A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
During a neurologic examination, which assessment should a nurse perform to test a client's balance?
A healthcare professional is reviewing a client's medication prescription, which reads, 'digoxin 0.25 by mouth every day.' Which of the following components of the prescription should the healthcare professional question?
A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?

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