a nurse is documenting client care which of the following abbreviations should the nurse use
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. When documenting client care, which of the following abbreviations should be used?

Correct answer: B

Rationale: When documenting client care, it is crucial to use standardized abbreviations to ensure clear communication and prevent misunderstandings. BRP for bathroom privileges is a recognized and commonly used abbreviation in healthcare settings. Choice A, SS for sliding scale, is not a standard abbreviation and can lead to confusion as it could be mistaken for other meanings. Choice C, OJ for orange juice, is informal and may not be universally understood in a healthcare context. Choice D, SQ for subcutaneous, is a valid abbreviation but may not be as relevant in the context of documenting client care compared to BRP, which is more specific and widely accepted.

2. A client who had a myocardial infarction (MI) 2 days ago has many questions about this condition. What area is a priority for the nurse to discuss at this time?

Correct answer: A

Rationale: Addressing the client's daily needs and concerns is a priority to help alleviate anxiety and ensure the client understands the immediate post-MI care. Daily needs and concerns encompass basic aspects like comfort, hygiene, emotional support, and overall well-being, which are crucial in the early recovery phase post-MI. Discussing cardiac rehabilitation, medication and diet guidelines, or activity and rest guidelines are important topics but addressing immediate personal needs and concerns takes precedence to establish a supportive and informative care environment.

3. A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.

4. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

Correct answer: B

Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.

5. During an assessment, a client receiving tube feedings via NG tube shows signs of nasal mucosa irritation. What finding should the nurse report to the provider?

Correct answer: B

Rationale: Irritation of nasal mucosa is a crucial finding that the nurse should report to the provider as it suggests potential complications with NG tube placement, such as improper positioning or mucosal damage. High potassium levels (Choice A) can be concerning but are not directly related to NG tube placement issues. Normal sodium levels (Choice C) and loose stools (Choice D) are common occurrences in clients receiving tube feedings and are not typically indicative of immediate complications that require urgent reporting.

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