a nurse is caring for a client who has a prescription for a vest restraint which of the following actions should the nurse take
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Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. A healthcare professional is caring for a client who has a prescription for a vest restraint. Which of the following actions should the healthcare professional take?

Correct answer: A

Rationale: The correct action for the healthcare professional to take when applying a vest restraint is to tie it with a quick-release knot. A quick-release knot allows for easy and rapid removal in case of an emergency, ensuring the safety of the client. Using a slipknot (Choice B) is not recommended as it may not provide quick release in emergencies. Ensuring the restraint is tightly secured (Choice C) can be dangerous as it can restrict circulation or cause discomfort. Attaching the restraint to the bed frame (Choice D) is inappropriate and can lead to potential harm or injury to the client.

2. What are the correct steps used for abdominal assessment?

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

3. When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?

Correct answer: C

Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.

4. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?

Correct answer: D

Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.

5. When providing hygiene for an older-adult patient, why does the nurse closely assess the skin?

Correct answer: B

Rationale: The correct answer is B: 'Less frequent bathing may be required.' In older adults, daily bathing or using hot water and harsh soap can lead to excessively dry skin. Therefore, the nurse closely assesses the skin to determine if less frequent bathing is necessary to prevent skin dryness and maintain skin integrity. Choice A is incorrect because the outer skin layer does not become less resilient with age. Choice C is incorrect as aging skin is actually more prone to bruising due to thinning of the skin. Choice D is incorrect because sweat gland activity generally decreases with age, leading to reduced skin moisture rather than increased activity.

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