a nurse is discussing the plan of care for a client who reports following islamic practices which of the following statements by the nurse indicates c
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Nursing Elites

HESI LPN

HESI Fundamentals Exam

1. Which statement by the nurse indicates culturally responsive care for a client following Islamic practices?

Correct answer: B

Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.

2. When assessing a client's skin turgor, a nurse should:

Correct answer: A

Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.

3. At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing:

Correct answer: B

Rationale: The correct technique for surgical handwashing involves scrubbing with hands held higher than the elbows. This positioning helps prevent water from the contaminated area (the hands) from flowing towards the cleaner area (the elbows). This directional flow minimizes the risk of contaminating the scrubbed hands during the handwashing process. Choices A, C, and D are incorrect: A - having hands lower than elbows would risk contamination of the clean area, C - using a fist position does not ensure proper coverage and thorough handwashing, and D - placing hands on the chest is not part of the proper surgical handwashing technique.

4. A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?

Correct answer: B

Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.

5. A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?

Correct answer: B

Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.

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