a nurse is assessing a clients oculomotor nerve functions which of the following actions should the nurse take
Logo

Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. A healthcare professional is assessing a client’s oculomotor nerve functions. Which of the following actions should the healthcare professional take?

Correct answer: A

Rationale: Checking the client’s pupillary reaction to light is a key assessment to evaluate the oculomotor nerve function. The oculomotor nerve controls the pupil's constriction response to light. Choices B, C, and D are incorrect because testing vision with a Snellen chart, identifying scents, or touching the cornea are not specific assessments for oculomotor nerve function.

2. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care?

Correct answer: A

Rationale: The correct answer is to infuse hypotonic IV fluids. In hypernatremia, there is an elevated sodium concentration in the blood, and diluting it with hypotonic fluids helps to lower the sodium levels. Implementing a fluid restriction or increasing sodium intake would worsen hypernatremia by further concentrating sodium in the body. Administering sodium polystyrene sulfonate is used for treating hyperkalemia, not hypernatremia.

3. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?

Correct answer: B

Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.

4. The client with chronic obstructive pulmonary disease (COPD) is being educated about lifestyle changes. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Clients with COPD should limit alcohol intake, not just to weekends, to effectively manage their condition. Excessive alcohol consumption can worsen respiratory symptoms and interfere with medications. Choices A, B, and D are all appropriate and beneficial for clients with COPD. Salt intake reduction helps in managing fluid retention and blood pressure. Regular exercise improves lung function and overall health. Monitoring blood pressure is crucial for individuals with COPD as hypertension is a common comorbidity.

5. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

Similar Questions

The nurse is caring for a patient who needs to be placed in the prone position. Which action will the nurse take?
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states, 'I demand to be released now!' The appropriate action is for the nurse to:
The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take?
The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?
The client with diabetes is being educated by the nurse on foot care. Which statement by the client indicates a need for further teaching?

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