a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes which of the following
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Nursing Elites

HESI LPN

HESI Practice Test for Fundamentals

1. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: Applying lotion to the feet, avoiding between toes, is correct; over-the-counter treatments and soaking are not recommended.

2. A 25-year-old primigravida at 16 weeks gestation is admitted to the hospital with a diagnosis of hyperemesis gravidarum. Which nursing diagnosis should have the highest priority?

Correct answer: A

Rationale: In a case of hyperemesis gravidarum, the priority nursing diagnosis should be addressing the Fluid volume deficit. This condition can lead to serious complications such as electrolyte imbalances and dehydration, which can endanger both the mother and the fetus if not managed promptly. Altered nutrition: less than body requirements is important but addressing the fluid volume deficit takes precedence as it poses an immediate threat. Anxiety related to new situational crisis and Activity intolerance related to fatigue are valid concerns, but they are secondary to the critical issue of fluid volume deficit in this scenario.

3. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Correct answer: C

Rationale: The correct answer is C - 'Reapplying a condom catheter for a client who has urinary incontinence.' This task falls within the scope of duties for an assistive personnel (AP). Updating care plans (Choice A), reinforcing teaching (Choice B), and applying sterile dressings (Choice D) typically require a higher level of training and expertise, making them tasks that should not be assigned to an AP. Assigning appropriate tasks based on skill levels ensures safe and effective patient care.

4. The patient is being treated for cancer with weekly radiation therapy to the head and intravenous chemotherapy treatments. Which assessment is the priority?

Correct answer: D

Rationale: The correct answer is the oral cavity. During cancer treatment involving radiation to the head and intravenous chemotherapy, the oral cavity is a priority assessment area. Radiation can reduce salivary flow and lower the pH of saliva, which can lead to stomatitis and tooth decay. Assessing the oral cavity allows for the early identification and management of potential complications. Choice A, assessing the feet, is not the priority in this scenario as it is not directly impacted by the described cancer treatments. Choice B, assessing the nail beds, is not the priority compared to the oral cavity. Nail bed assessment may be relevant for certain conditions, but in this case, the oral cavity is of higher priority due to the specific treatment effects. Choice C, assessing the perineum, is also not the priority in this situation as it is not directly affected by the described cancer treatments, unlike the oral cavity.

5. What action should the nurse include in the plan of care for a postoperative client with a history of poor nutritional intake who needs care for wound healing?

Correct answer: A

Rationale: To promote wound healing in a postoperative client with poor nutritional intake, the nurse should include a protein intake of 1.5 g/kg of body weight per day in the plan of care. Proteins are essential for tissue repair and wound healing. Increasing carbohydrate intake or administering high-dose vitamin supplements may not directly promote wound healing. Ensuring a daily intake of 1000 calories may not provide adequate nutrients for optimal wound healing.

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