a 65 year old client who attends an adult daycare program and is wheelchair mobile has redness in the sacral arewhich instruction is most important fo
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Nursing Elites

HESI RN

HESI Fundamentals

1. What is the most important instruction for the nurse to provide to a 65-year-old client who attends an adult daycare program, is wheelchair-mobile, and has redness in the sacral area?

Correct answer: B

Rationale: For a client with redness in the sacral area, the most critical instruction is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, which can develop due to prolonged pressure on the skin and underlying tissues. Regular position changes help relieve pressure on vulnerable areas, promoting circulation and reducing the risk of skin breakdown and pressure ulcer formation.

2. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

Correct answer: C

Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.

3. The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

Correct answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

4. A client with a diagnosis of anemia is receiving epoetin alfa (Epogen). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

Correct answer: B

Rationale: To evaluate the effectiveness of epoetin alfa (Epogen) in treating anemia, the nurse should monitor hemoglobin and hematocrit levels. These values indicate the oxygen-carrying capacity of the blood, which directly relates to the treatment of anemia. White blood cell count (A), platelet count (C), and blood urea nitrogen (BUN) and creatinine (D) are not specific indicators of the effectiveness of epoetin alfa in treating anemia.

5. The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

Correct answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

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