a nurse is providing discharge teaching to a client about self administering heparin
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Nursing Elites

HESI LPN

HESI Fundamentals Test Bank

1. A healthcare provider is providing discharge teaching to a client about self-administering heparin.

Correct answer: A

Rationale: Heparin is typically administered in the abdomen for self-injection to avoid muscle tissue and for better absorption. The subcutaneous tissue in the abdomen provides a larger area for injection and is usually recommended for heparin administration. Administering heparin in the thigh, upper arm, or buttock may not be as effective or safe as the abdomen due to variations in absorption rates and potential risks associated with muscle injection.

2. When reviewing a client’s fluid and electrolyte status, what should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.

3. A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

Correct answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

4. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is MOST critical for the nurse to include in the plan of care?

Correct answer: A

Rationale: Monitoring hourly urine output is crucial after successful resuscitation from a pulseless dysrhythmia to assess kidney function and perfusion. The kidneys are particularly vulnerable to injury following cardiac events due to decreased perfusion during the event. Evaluating urine output hourly allows for early detection of renal impairment or inadequate organ perfusion. Option B, monitoring white blood cell count, is not a priority in this situation as it does not directly relate to immediate post-resuscitation care. Option C, checking blood glucose every 4 hours, is important but not as critical as assessing kidney function and perfusion. Option D, measuring temperature every 2 hours, is relevant for monitoring signs of infection or inflammatory response but is not as crucial as assessing kidney function in this scenario.

5. A client who is postoperative is being taught how to use a flow-oriented incentive spirometer. Which of the following instructions should be included by the nurse?

Correct answer: C

Rationale: The correct technique for using a flow-oriented incentive spirometer involves breathing in slowly and deeply to raise the ball or piston. This action helps to expand the lungs and improve lung function. Option A is incorrect as coughing deeply after each use is not part of using the spirometer. Option B is incorrect as holding the breath for 10 seconds is not the correct instruction for using the spirometer. Option D is incorrect as exhaling forcefully before using the spirometer is not the appropriate step in using this device.

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