a clients daughter phones the charge nurse to report that the night nurse did not provide good care for her mother what response should the nurse make
Logo

Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

Correct answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

2. The nurse observes that a post-operative client's surgical wound has reddened edges and is oozing. What is the appropriate nursing action?

Correct answer: D

Rationale: The correct action when a post-operative client's surgical wound has reddened edges and is oozing is to notify the surgeon immediately. Reddened, oozing wound edges can indicate an infection that requires prompt evaluation and intervention by the surgical team. Applying an antibiotic ointment (Choice A) without proper assessment and guidance can be inappropriate. Cleaning the wound with sterile saline (Choice B) and covering it with a sterile dressing (Choice C) may not address the potential infection adequately, and the client may require more specialized care that the surgeon can provide.

3. In a community health setting, which individual is at highest risk for contracting an HIV infection?

Correct answer: C

Rationale: The correct answer is C. Substance abuse, particularly using shared inhalation equipment like needles and pipes for drug inhalation, significantly increases the risk of contracting HIV. Choice A, the 17-year-old with multiple sexual partners, poses a risk of HIV transmission through sexual contact, but it is lower compared to the direct risk associated with sharing drug paraphernalia. Choice B, the 34-year-old homosexual in a monogamous relationship, is at lower risk since being in a monogamous relationship reduces exposure to HIV. Choice D, the 45-year-old who received blood transfusions, is also at lower risk as blood transfusions are now screened for HIV, decreasing the likelihood of transmission through this route.

4. A client with a history of congestive heart failure is prescribed digoxin (Lanoxin). Which assessment is most important for the nurse to obtain before administering this medication?

Correct answer: B

Rationale: The correct answer is B: Heart rate. Before administering digoxin to a client with a history of congestive heart failure, the nurse must assess the client's heart rate. Digoxin can cause bradycardia, so monitoring the heart rate is crucial to prevent potential complications. Assessing blood pressure, respiratory rate, and oxygen saturation are important assessments but are not as directly influenced by digoxin as heart rate is in this scenario. Blood pressure can be affected by various factors, including dehydration or other medications. Respiratory rate and oxygen saturation are more related to respiratory function and gas exchange, which are not the primary concerns when administering digoxin to a client with heart failure.

5. Which client assessment falls within the scope of practice for the practical nurse?

Correct answer: B

Rationale: The correct answer is B because assessing a new deep vein thrombosis (DVT) patient is within the scope of practical nursing. It involves monitoring and supporting the circulatory system health, which is a common responsibility for practical nurses. Choices A, C, and D involve scenarios that are typically beyond the initial assessment and care provided by practical nurses. An agitated client with bilateral wrist restraints may require immediate intervention by higher-level healthcare providers due to safety concerns and potential underlying issues. The return of a post-anesthesia client following a colon resection and the transfer of a client with sepsis involve more specialized care that goes beyond the typical responsibilities of a practical nurse, often requiring interventions from registered nurses or physicians.

Similar Questions

The nurse is preparing a client for discharge following a myocardial infarction. What should the nurse prioritize in the discharge instructions?
A client is diagnosed with type 1 diabetes mellitus. Which instruction about insulin administration should the nurse emphasize?
When teaching a diabetic client about foot care, what information is most important?
How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?
A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses