a nurse receives a report about a client who has 09 sodium chloride infusing iv at 125 mlhr when the nurse performs the initial assessment he notes th
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HESI LPN

HESI Fundamentals Test Bank

1. A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, they note that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

Correct answer: A

Rationale: The correct first action for the nurse to take in this situation is to check the IV tubing for obstruction. By doing this, the nurse can assess if there is any blockage or kink in the tubing that is impeding the flow of the IV solution. This step is crucial as it helps in identifying the reason for the inadequate infusion rate. Increasing the infusion rate (Choice B) without first checking for obstructions can lead to potential complications if there is a blockage. Administering a bolus of fluid (Choice C) may not be appropriate without addressing the cause of the decreased infusion rate. Similarly, replacing the IV catheter (Choice D) is not the initial priority unless obstruction is ruled out and other troubleshooting measures have been taken.

2. A healthcare professional is preparing to administer metoprolol 200 mg PO daily. The medication available is metoprolol 100 mg/tablet. How many tablets should the healthcare professional administer? (Round the answer to the nearest whole number. Do not use a trailing zero.)

Correct answer: B

Rationale: To administer 200 mg of metoprolol using 100 mg tablets, the healthcare professional should give 2 tablets. Each tablet contains 100 mg of metoprolol, so 2 tablets will provide the required 200 mg dose. Choice A is incorrect because 1 tablet would only provide 100 mg, which is insufficient. Choice C is incorrect as fractions of tablets are usually not used in practice to ensure accurate dosing. Choice D is incorrect as it would result in an overdose, providing 400 mg instead of the prescribed 200 mg.

3. A healthcare professional is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the professional will improve the clients' commitment to a long-term goal of weight loss?

Correct answer: A

Rationale: Helping the clients increase their self-motivation is crucial for long-term weight loss success. By empowering clients to find their internal drive to make healthy choices, they are more likely to stay committed to their goals. Choice B is incorrect because recommending a strict diet plan immediately may not consider the clients' individual preferences and needs, leading to potential disengagement. Choice C is incorrect as focusing solely on exercise without addressing dietary changes does not provide a comprehensive approach to weight loss. Choice D is incorrect because setting only short-term goals may not foster sustained progress towards achieving a healthier weight.

4. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take?

Correct answer: D

Rationale: Re-assessing the client's situation before providing care is the most appropriate action in this scenario. By re-evaluating the client, the nurse can better understand the cause of the anxiety and tailor the care accordingly. Diverting the client's attention (Choice A) may not address the underlying issue causing anxiety. Calling for additional help (Choice B) is not the initial step required unless there is an urgent need. Documenting the planned action (Choice C) should come after reassessing the client to ensure accuracy and relevance.

5. When performing nasotracheal suctioning for a client with a respiratory infection, what technique should the nurse use?

Correct answer: A

Rationale: When performing nasotracheal suctioning for a client with a respiratory infection, the nurse should apply intermittent suction when withdrawing the catheter. This technique helps minimize mucosal damage and is considered best practice. Choice B, suctioning continuously while inserting the catheter, is incorrect as continuous suctioning can cause trauma to the airway. Choice C, suctioning intermittently while inserting the catheter, is also incorrect as it can increase the risk of hypoxia and mucosal damage. Choice D, using a Yankauer suction device, is not appropriate for nasotracheal suctioning as it is typically used for oral suctioning. Therefore, the correct technique is to apply intermittent suction when withdrawing the catheter to ensure effective and safe suctioning.

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