a nurse is planning care for a client who has a prescription for knee length anti embolic stockings which of the following actions should the nurse ta
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. A nurse is planning care for a client who has a prescription for knee-length anti-embolic stockings. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take is to remove the client’s stockings at least once during each shift. This is important to inspect the skin and prevent complications such as pressure injuries or impaired circulation. Rolling the top of the stockings down can compromise their effectiveness in preventing blood clots. Seating the client in a chair prior to applying stockings is not directly related to the care of anti-embolic stockings. Measuring the length of the client’s leg from the heel to the gluteal fold is not necessary for the application or care of knee-length anti-embolic stockings.

2. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

3. A patient is placed in the Sims' position. Which areas will the nurse observe for pressure points?

Correct answer: B

Rationale: When a patient is placed in the Sims' position, the nurse should observe pressure points on the ileum, clavicle, humerus, knees, and ankles. Choice A is incorrect as the chin and hips are not typically pressure points in the Sims' position. Choice C is incorrect as the shoulder and anterior iliac spine are not commonly observed pressure points in this position. Choice D is also incorrect as the occipital region of the head, coccyx, and heels are not pressure points commonly associated with the Sims' position.

4. A healthcare professional is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the professional will improve the clients' commitment to a long-term goal of weight loss?

Correct answer: A

Rationale: Helping the clients increase their self-motivation is crucial for long-term weight loss success. By empowering clients to find their internal drive to make healthy choices, they are more likely to stay committed to their goals. Choice B is incorrect because recommending a strict diet plan immediately may not consider the clients' individual preferences and needs, leading to potential disengagement. Choice C is incorrect as focusing solely on exercise without addressing dietary changes does not provide a comprehensive approach to weight loss. Choice D is incorrect because setting only short-term goals may not foster sustained progress towards achieving a healthier weight.

5. A client has pharyngeal diphtheria. What transmission precautions are necessary?

Correct answer: A

Rationale: Pharyngeal diphtheria is primarily spread through droplet transmission, which occurs when an infected person coughs, sneezes, or talks, releasing respiratory droplets containing the bacteria. Therefore, the correct precaution for caring for a client with pharyngeal diphtheria is droplet precautions. Droplet precautions help prevent the transmission of respiratory pathogens over short distances via respiratory droplets. Contact precautions are used for diseases spread through direct or indirect contact with the patient or their environment. Airborne precautions are used for diseases that spread through small droplets suspended in the air. Standard precautions are basic infection prevention practices applying to all patient care.

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