a nurse is assessing the body alignment of a standing patient which finding will the nurse report as normal
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

2. How should the nurse transcribe the dosage of this medication on the client's medical record?

Correct answer: B

Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.

3. A healthcare professional is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 min. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)

Correct answer: A

Rationale: To administer 100 mL over 15 min, the IV pump should be set to deliver 400 mL/hr. This calculation is based on the concept that if 100 mL is given in 15 minutes, to find out how many milliliters are given in an hour, you would multiply by 4 (since 15 minutes is a quarter of an hour). Therefore, 100 mL x 4 = 400 mL per hour. Choices B, C, and D are incorrect as they do not reflect the correct calculation for the infusion rate required to administer 100 mL over 15 minutes.

4. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?

Correct answer: A

Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.

5. While reviewing the medical records of a client with a pressure ulcer, a nurse should expect which of the following findings?

Correct answer: A

Rationale: An albumin level below 3.5 g/dL indicates protein deficiency, which can impair wound healing and contribute to pressure ulcer formation. Hemoglobin level and WBC count are not directly associated with pressure ulcers. Blood glucose level, while important for overall health, is not specifically linked to pressure ulcer development.

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