a nurse on a medical surgical unit is admitting a client which of the following information should the nurse document in the clients record first
Logo

Nursing Elites

HESI LPN

Fundamentals HESI

1. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first?

Correct answer: D

Rationale: When admitting a client to a medical-surgical unit, documenting the admission date and time is crucial as it establishes the timeline for the client's care. This information ensures accurate tracking of interventions and facilitates communication among the healthcare team. While assessment, history of present illness, and plan of care are important components of the admission process, documenting the admission date and time takes priority to establish a baseline for care delivery. Without the admission date and time, the continuity of care and coordination among healthcare providers may be compromised.

2. When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?

Correct answer: A

Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.

3. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further?

Correct answer: D

Rationale: The statement about feeling unprepared to be a good parent indicates a significant concern that may need further assessment and support. This statement raises issues regarding the individual's readiness for parenthood and potential impact on the partner and the unborn child. Choices A, B, and C, while important, do not present immediate concerns regarding the well-being of another individual and do not raise potential risks that could have a direct impact on others.

4. A child weighing 20 kg has a new prescription for cefoxitin at 80 mg/kg/day administered intravenously every 6 hours. How much cefoxitin should be administered with each dose?

Correct answer: A

Rationale: To determine the amount of cefoxitin to be administered with each dose, first, calculate the total daily dose by multiplying the child's weight (20 kg) by the prescribed dose (80 mg/kg/day): 80 mg/kg/day × 20 kg = 1600 mg/day. Since the medication is administered every 6 hours (4 doses/day), divide the total daily dose by the number of doses: 1600 mg / 4 = 400 mg. Therefore, each dose should be 400 mg. Choice B (200 mg) is incorrect because it is half the calculated dose. Choice C (1600 mg) is incorrect as it represents the total daily dose, not the dose per administration. Choice D (100 mg) is incorrect as it is a quarter of the calculated dose.

5. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

Similar Questions

A client with chronic renal failure selects scrambled eggs for breakfast. What action should the LPN/LVN take?
A client with amphetamine toxicity and sensory overload is being cared for by a nurse. Which intervention should the nurse implement?
The nurse is caring for a client with a tracheostomy who is unable to clear secretions by coughing. What is the most appropriate action for the nurse to take?
A client who is lactating is being taught about taking medications by a nurse. Which of the following actions should the nurse recommend to minimize the entry of medication into breast milk?
When admitting a client with an abdominal wound, which precaution should be taken?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses