when evaluating a clients plan of care the lpn determines that a desired outcome was not achievewhich action will the lpn implement first
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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. A client is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates that the client understands the importance of communicating with the nurse if the pain persists while using the PCA device. This is crucial as it ensures proper pain management and monitoring. Choices A and B are incorrect because delaying the use of the device until necessary or being cautious about pushing the button too much do not necessarily reflect understanding of using the PCA device effectively. Choice D is incorrect as having someone else, like an adult child, push the dose button goes against the principle of the client self-administering the medication through the PCA device.

3. A nurse in a surgical suite notes documentation on a client's medical record stating that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Correct answer: B

Rationale: In this scenario, the nurse should take precautions to prevent latex exposure to the client due to his latex allergy. Wrapping monitoring cords with stockinette and securing them with non-latex tape helps to minimize the risk of latex contact with the client. Choice A is incorrect as sterilizing non-disposable items with ethylene oxide does not specifically address the avoidance of latex exposure. Choice C involves using latex ports on IV tubing, which can pose a risk of allergic reaction in a client with a latex allergy. Choice D suggests wearing latex gloves, even if hypoallergenic, which can still trigger a reaction in individuals with latex allergy. Therefore, the best option is to choose non-latex materials like stockinette and non-latex tape to prevent direct contact with latex.

4. A healthcare professional is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the professional assess for?

Correct answer: D

Rationale: Correct. Loss of hope is a significant psychosocial aspect that healthcare professionals should assess for in patients who are immobile. Immobility can lead to feelings of hopelessness and depression, impacting the patient's mental well-being. Assessing for loss of hope allows healthcare professionals to provide appropriate support and interventions to address the patient's emotional needs. Choices A, B, and C are incorrect because they primarily relate to physical changes (bone mass, strength, weight) rather than the psychosocial aspect of hope.

5. The caregiver is teaching parents about accidental poisoning in children. Which point should be emphasized?

Correct answer: B

Rationale: The correct answer is to emphasize emptying the child's mouth in any case of possible poisoning. This action is crucial to prevent further ingestion of the poisonous substance. Choice A is incorrect because calling the Poison Control Center should be one of the first steps, not waiting until the situation is identified. Choice C is incorrect as moving the child may spread or exacerbate the effects of the toxic substance. Choice D is incorrect because inducing vomiting can be harmful if the poison is a hydrocarbon, as it may lead to aspiration.

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