a nurse is preparing to perform nasal tracheal suctioning for a client which of the following is an appropriate action for the nurse to take
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Nursing Elites

HESI LPN

Practice HESI Fundamentals Exam

1. A healthcare professional is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the healthcare professional to take?

Correct answer: D

Rationale: Using surgical asepsis when performing nasal tracheal suctioning is crucial to prevent infection. Choice A is incorrect because the suction catheter should be held with the dominant hand to ensure better control and precision during the procedure. Choice B is incorrect as suctioning should be applied for no longer than 10 to 15 seconds to avoid trauma to the mucous membranes. Choice C is incorrect as the catheter should be disposed of properly after single-use to prevent cross-contamination and infection.

2. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?

Correct answer: A

Rationale: The correct answer is A: Pain related to ischemia. This nursing diagnosis should have priority because addressing the pain caused by ischemia is crucial in managing the client's myocardial infarction. Pain management is essential not only for the client's comfort but also for improving outcomes and reducing complications. Choices B, C, and D are not the priority in this scenario. Risk for altered elimination: constipation (Choice B) is not as immediate a concern as managing the client's pain. Risk for complication: dysrhythmias (Choice C) may be a potential concern but addressing the client's pain takes precedence. Anxiety related to pain (Choice D) is important to address but should come after managing the pain itself.

3. A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?

Correct answer: B

Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.

4. During a staff meeting, a nurse is discussing the purpose of regulatory agencies. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?

Correct answer: B

Rationale: State licensing boards are primarily responsible for ensuring that health care providers comply with regulations. This includes overseeing licensure requirements, investigating complaints, and enforcing disciplinary actions. Monitoring evidence-based practice for clients with specific diagnoses is typically within the domain of professional organizations or healthcare institutions. Setting quality standards for accrediting health care facilities is usually the role of accrediting bodies such as The Joint Commission. Lastly, determining the safety of medications for administration to clients falls under the purview of regulatory agencies like the Food and Drug Administration (FDA).

5. A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client?

Correct answer: A

Rationale: The correct instruction for the nurse to give the client who is starting on antihypertensive medication is to 'Get up and change positions slowly.' Antihypertensive medications can cause orthostatic hypotension, a drop in blood pressure when changing positions, so changing positions slowly helps prevent this adverse effect. Choice B about avoiding aged cheese and smoked meat is more relevant for clients taking monoamine oxidase inhibitors (MAOIs) due to potential interactions. Choice C regarding reporting unusual bruising or bleeding is more applicable for clients on anticoagulants. Choice D about consuming consistent amounts of vitamin K-containing foods daily is important for clients taking warfarin, not antihypertensive medications.

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