a nurse is ambulating a client who is unsteady the client begins to fall which of the following actions should the nurse take
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Quizlet

1. While ambulating an unsteady client who begins to fall, which of the following actions should the nurse take?

Correct answer: A

Rationale: When a client is falling, allowing them to slide down your leg can help control the descent and prevent injury. This technique ensures a more controlled fall compared to attempting to catch or stop the client abruptly, which could lead to both the client and the nurse getting injured. Placing arms around the client may not provide enough support or control during the fall. Remaining upright or moving quickly in front of the client might not be practical or safe in this scenario.

2. A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?

Correct answer: A

Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.

3. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement?

Correct answer: D

Rationale: Encouraging additional oral intake of juices and water is the appropriate intervention in this scenario. Dark amber urine can indicate concentrated urine due to dehydration or other factors. By encouraging more fluids, the LPN/LVN can help dilute the urine, reducing the concentration of pigments causing the dark color. Providing additional coffee (Choice A) would not necessarily increase hydration and could potentially have a diuretic effect. Exchanging grape juice for cranberry juice (Choice B) does not address the core issue of hydration. Bringing additional fruit (Choice C) may provide some fluid, but encouraging specific fluids like juices and water would be more effective in diluting the urine.

4. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?

Correct answer: C

Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.

5. A client reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?

Correct answer: B

Rationale: Offering a wet washcloth for the client to wash their face is a soothing and calming activity that can help the client relax before bedtime, promoting better sleep. Providing a late supper can lead to indigestion and disrupt sleep. Performing range of motion exercises may increase alertness rather than promoting relaxation. Preparing a hot cocoa or tea containing caffeine close to bedtime can interfere with falling asleep.

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