a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair to prevent self injury which of the following actions sho
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Nursing Elites

HESI LPN

HESI Fundamentals Study Guide

1. When lifting a bedside cabinet to move it closer to a client who is sitting in a chair, which of the following actions should the nurse take to prevent self-injury?

Correct answer: D

Rationale: The correct answer is to stand close to the cabinet when lifting it. This action keeps the object close to the nurse's center of gravity, reducing the risk of back strain. Bending at the waist (Choice A) can increase the risk of back injury as it puts strain on the lower back. Keeping feet close together (Choice B) does not provide a stable base of support for lifting a heavy object. Using back muscles for lifting (Choice C) is incorrect as it can lead to back strain and injury. Therefore, standing close to the cabinet when lifting it is the safest and most effective approach to prevent self-injury.

2. A healthcare provider is witnessing a client sign an informed consent form for surgery. Which of the following describes what the healthcare provider is affirming by this action?

Correct answer: A

Rationale: The correct answer is A. When a healthcare provider witnesses a client signing an informed consent form for surgery, they are affirming that the signature on the form belongs to the client. This is crucial for ensuring patient autonomy and informed decision-making. Choices B, C, and D are incorrect because while it is important for the client to understand the risks of surgery, be aware of postoperative care instructions, and have an opportunity to ask questions, these elements are not specifically affirmed by the healthcare provider witnessing the signature.

3. A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client’s ability to learn new dietary habits?

Correct answer: D

Rationale: The client’s previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

4. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

5. A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.)

Correct answer: A

Rationale: The correct statement is: 'The temperature around the IV site is cooler.' Cooler temperature around the site is indicative of infiltration, where IV fluid leaks into the surrounding tissue, causing tissue swelling. The other options are incorrect: B) An increase in infusion rate is not a sign of infiltration; instead, it could indicate an issue with the infusion pump or the IV catheter. C) Redness around the IV site is more indicative of infection rather than infiltration. D) A damp IV dressing is more suggestive of a leak in the IV system, not infiltration.

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