which of the following times is a depressed client at highest risk for attempting suicide
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Nursing Elites

HESI LPN

HESI Fundamentals Practice Questions

1. 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.

2. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP), and 1 PN nursing student. Which assignment should be questioned by the nurse manager?

Correct answer: A

Rationale: Assigning an admission with atrial fibrillation and heart failure to a PN is not appropriate. This complex case requires more advanced skills and should not be managed by a PN without adequate support. The PN may not have the necessary training or expertise to handle such a critical situation effectively. Choice B is a suitable assignment for a PN nursing student as they can handle a client who had a major stroke 6 days ago. Choice C is also appropriate as a child with burns receiving packed cells and albumin IV running can be managed by the charge nurse. Choice D is within the scope of practice for a UAP since an elderly client post-myocardial infarction a week ago may require basic care and assistance.

3. The healthcare professional is assessing a client with a history of rheumatoid arthritis. Which of the following assessment findings would be most concerning?

Correct answer: C

Rationale: In a client with rheumatoid arthritis, the presence of fever is most concerning because it may indicate an infection or systemic involvement, necessitating immediate attention. Morning stiffness and joint deformities are common manifestations of rheumatoid arthritis itself and are expected findings in these clients. Weight loss can occur in rheumatoid arthritis due to various factors such as decreased appetite or systemic inflammation, but it is not as acutely concerning as fever, which may signal a more urgent issue.

4. A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: When preparing to insert an IV catheter, stroking the extremity before insertion helps to visualize veins, making it easier to locate a suitable vein for catheter insertion. Choosing the most distal site on the extremity is correct because veins more distal are preferred for IV catheter insertion. Applying a cool compress to the extremity before insertion is unnecessary and not a standard practice. Placing the tourniquet below the proposed insertion site is incorrect; the tourniquet should be placed above the proposed insertion site to help engorge the veins for easier visualization and access.

5. A healthcare professional is preparing to insert an IV catheter into a client’s arm prior to initiating IV fluid therapy. Which of the following interventions should the healthcare professional implement to prevent infection?

Correct answer: B

Rationale: Using a sterile technique throughout the procedure is essential to prevent infection when inserting an IV catheter. This includes maintaining aseptic conditions, using sterile equipment, and following proper hand hygiene practices. Choice A is incorrect because threading the catheter up to the hub does not specifically address infection prevention. Choice C is incorrect as cleaning the insertion site with alcohol only may not provide adequate disinfection, as it is essential to use an antiseptic solution to reduce microbial load. Choice D is incorrect as wearing gloves alone is not sufficient protection against infection; a mask should also be worn to prevent the spread of microorganisms through respiratory secretions.

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