a client with a history of chronic obstructive pulmonary disease copd is receiving oxygen therapy at 2 liters per minute via nasal cannulwhat is the m
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HESI LPN

HESI Fundamentals Test Bank

1. What is the most important assessment for the LPN/LVN to perform on a client with a history of chronic obstructive pulmonary disease (COPD) receiving oxygen therapy at 2 liters per minute via nasal cannula?

Correct answer: B

Rationale: Measuring the client's oxygen saturation level is the most important assessment in this scenario. Oxygen saturation level reflects how well the client is oxygenating, which is crucial in assessing the effectiveness of oxygen therapy for a client with COPD. Monitoring the respiratory rate and effort (Choice A) is important but assessing oxygenation with saturation levels takes precedence. While arterial blood gas levels (Choice C) provide comprehensive information, checking oxygen saturation is a quicker and more immediate way to assess oxygenation status. Checking blood pressure (Choice D) is not the priority when evaluating the effectiveness of oxygen therapy in COPD.

2. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

Correct answer: A

Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.

3. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Correct answer: A

Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.

4. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:

Correct answer: A

Rationale: The correct procedure when obtaining a urine specimen from an indwelling catheter for culture and sensitivity is to cleanse the entry port before withdrawing urine. This step helps reduce the risk of contamination and ensures the accuracy of the results. Option B is incorrect because using a sterile syringe to collect urine from the collection bag is not the recommended method for obtaining a catheter specimen. Option C is incorrect as obtaining the specimen from the drainage tubing is not the appropriate technique for collecting a urine sample from an indwelling catheter. Option D is incorrect because replacing the catheter before obtaining the specimen is not necessary and may introduce unnecessary complications.

5. The nurse is caring for a client diagnosed with hypothyroidism. Which finding should the nurse expect to observe?

Correct answer: A

Rationale: The correct answer is weight gain. In hypothyroidism, there is a decrease in metabolic rate, which can lead to weight gain. Heat intolerance (choice B) is more commonly associated with hyperthyroidism. Increased appetite (choice C) and frequent diarrhea (choice D) are not typical findings in hypothyroidism. Therefore, choices B, C, and D are incorrect.

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