while changing the linen on the clients bed the nurse should
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Nursing Elites

HESI LPN

HESI Fundamentals Test Bank

1. While changing the linen on the client's bed, what should the nurse do?

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

2. The patient is receiving chemotherapy for breast cancer. Which of the following laboratory values would be most important to monitor?

Correct answer: A

Rationale: Monitoring the white blood cell count is crucial when a patient is undergoing chemotherapy for breast cancer. Chemotherapy can lead to neutropenia, a condition of low white blood cell count, which significantly increases the risk of infections. Monitoring white blood cell count helps healthcare providers intervene promptly to prevent severe infections. Hemoglobin level, while important in assessing oxygen-carrying capacity, is not the priority in this scenario. Serum creatinine and blood glucose levels are not directly impacted by chemotherapy for breast cancer.

3. While caring for a client who begins to experience a generalized seizure while standing in her room, which of the following actions should the nurse take?

Correct answer: A

Rationale: During a seizure, the priority is to protect the client's head and ensure their safety. The nurse should guide the client to the ground if possible and place a soft pad or a folded cloth under the head to prevent injury. Restraining the client's limbs can result in injury and should be avoided. Lifting the client can also lead to injuries during a seizure. Inserting a bite block is contraindicated as it can cause damage to the teeth, oral tissues, and obstruct the airway. Therefore, the correct action is to place a pad under the client's head to protect them during the seizure.

4. To minimize the side effects of vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include?

Correct answer: C

Rationale: The correct answer is to include a diet high in fluids to help minimize the side effects of vincristine. High fluid intake is important in managing potential side effects such as constipation, which is a common issue associated with vincristine therapy. Options A, B, and D are incorrect. A diet low in fat or high in iron is not specifically indicated for managing vincristine side effects. Additionally, a diet low in residue is not directly related to addressing vincristine side effects.

5. During a change-of-shift report at a long-term care facility, a nurse discusses an older adult client with shingles with an oncoming nurse. What information should the nurse include in the report?

Correct answer: D

Rationale: The correct answer is to include the type of transmission-based precautions in the report. This information is crucial for infection control when caring for a client with shingles, as it helps prevent the spread of the virus to other clients and healthcare workers. Choices A, B, and C are not directly related to managing a client with shingles. Option A about the location of breakfast is irrelevant to the client's condition. Option B about vital sign measurements, though important, is not the priority when discussing a client with shingles. Option C mentions 'specific times the client had visitors,' which is not as crucial as knowing the specific precautions in place to prevent transmission of the virus.

Similar Questions

A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel?
After repositioning a client who reports shortness of breath, which of the following actions should the nurse take next?
A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?
When assessing the respiratory system for complications of immobility, what action should the nurse take?

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