a client who is post op following laparotomy is reporting pain and dry mouth the client has morphine sulfate ordered to control the pain before admini
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Nursing Elites

HESI LPN

HESI Fundamentals Study Guide

1. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

2. A client has extracellular fluid volume deficit. Which of the following findings should the nurse expect?

Correct answer: A

Rationale: Postural hypotension is a common sign of extracellular fluid volume deficit due to decreased blood volume, leading to a drop in blood pressure upon standing. Distended neck veins, dependent edema, and bradycardia are not typically associated with extracellular fluid volume deficit. Distended neck veins are more indicative of fluid volume overload, dependent edema is a sign of fluid retention, and bradycardia is not a common finding in extracellular fluid volume deficit.

3. A nurse is evaluating a client’s use of a cane. What is the correct use?

Correct answer: A

Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.

4. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.

5. A client has a new diagnosis of hypothyroidism. Which of the following interventions should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct intervention for a client with hypothyroidism is to encourage frequent rest periods. Hypothyroidism often leads to fatigue, making rest essential for recovery and symptom management. Providing a high-calorie diet is not necessary unless the client has gained weight due to hypothyroidism. Restricting fluid intake is not indicated unless there are specific medical reasons for it. Increasing iodine intake is not recommended for primary hypothyroidism, as it is typically caused by autoimmune thyroiditis or other factors rather than iodine deficiency.

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