when evaluating a clients plan of care the lpn determines that a desired outcome was not achievewhich action will the lpn implement first
Logo

Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first?

Correct answer: B

Rationale: The correct first action for the LPN to take when a desired outcome is not achieved is to note which actions were not implemented. This step helps in identifying gaps in the plan of care and reasons for not achieving the desired outcome. Establishing a new nursing diagnosis (Choice A) is not the initial step when evaluating the plan of care. Adding additional nursing orders (Choice C) may not address the root cause of the unachieved outcome. Collaborating with the healthcare provider (Choice D) should come after identifying the gaps in the plan and reasons for the outcome not being met.

2. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?

Correct answer: D

Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.

3. When is a depressed client at highest risk for attempting suicide?

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

4. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

5. A client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?

Correct answer: A

Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.

Similar Questions

A healthcare professional in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. Which of the following findings should the healthcare professional identify as an indication that the client has an infection?
A healthcare professional is preparing to administer IV fluids to a client. The professional notes sparks when plugging in the IV pump. Which of the following actions should the professional take first?
A healthcare professional uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the healthcare professional demonstrate?
During an abdominal assessment for an adult client, what is the correct sequence of steps?
A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?

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