a nurse is responding to a call light and finds a client lying on the bathroom floor which of the following actions should the nurse take first
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. A client is lying on the bathroom floor after a nurse responds to a call light. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The nurse's priority in this situation is to assess the client for injuries. Checking for injuries first is crucial to determine the extent of harm caused by the fall and to provide immediate care. Moving hazardous objects can wait until the client's safety is ensured. Notifying the provider and asking the client about how she felt prior to the fall are important but are secondary to assessing for injuries in this urgent scenario. It is essential to address immediate physical needs before investigating the cause of the fall or notifying other healthcare team members.

2. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

Correct answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

3. During an abdominal assessment for an adult client, what is the correct sequence of steps?

Correct answer: A

Rationale: The correct sequence for an abdominal assessment in an adult client is to first Inspect the abdomen for any visible abnormalities, then Auscultate to listen for bowel sounds, followed by Percussion to assess for organ size and presence of fluid or masses, and finally Palpation to feel for tenderness, masses, or organ enlargement. Choice A, 'Inspect, Auscultate, Percuss, Palpate,' is the correct sequence for an abdominal assessment. Choices B, C, and D are incorrect because they do not follow the recommended sequence of assessment. Palpation should be the last step as it can potentially alter bowel sounds and percussion findings if done before. This deviation can lead to missing important findings or inaccurate assessment results.

4. A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?

Correct answer: A

Rationale: When the cerebellum is damaged, it leads to impaired balance. The cerebellum plays a crucial role in coordinating movements and maintaining balance. Therefore, assessing the patient's balance is essential in determining the extent of cerebellar damage. Options B, C, and D are incorrect because hemiplegia refers to paralysis of one side of the body, muscle sprain is a soft tissue injury, and lower extremity paralysis involves loss of function in the lower limbs. These conditions are not directly associated with damage to the cerebellum.

5. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?

Correct answer: B

Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.

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