a postoperative client says to the nurse my neighbor i mean the person in the next room sings all night and keeps me awake the neighboring client has
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Nursing Elites

HESI LPN

HESI Fundamentals Exam

1. How can the LPN/LVN best handle the situation of a postoperative client being kept awake by a neighboring client with dementia who sings all night?

Correct answer: D

Rationale: The best way to handle the situation in this scenario is to move the neighboring client to a room at the end of the hall. This solution is considerate to both clients because it addresses the issue by providing a quieter environment for the client with dementia while allowing the postoperative client to rest. Choice A is inappropriate as it does not address the root cause of the problem and may not be feasible or respectful. Choice B of closing the doors may not effectively reduce the noise disturbance. Choice C of giving the complaining client sedatives should be the last resort and not the initial solution, as it does not address the underlying issue causing the disturbance.

2. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Correct answer: B

Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.

3. Which nursing diagnosis would be a priority for a client admitted with a CVA (cerebral vascular accident)?

Correct answer: A

Rationale: The correct answer is 'Risk for aspiration' as it is a priority concern in clients with a CVA due to potential swallowing difficulties. Aspiration poses immediate risks such as pneumonia, which can be life-threatening. Impaired physical mobility, while important, may not be as urgent as the risk for aspiration in this scenario. Disturbed sensory perception and interrupted family processes are not typically the most critical concerns in the acute phase of a CVA.

4. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement?

Correct answer: D

Rationale: The correct intervention is to give the missed dose at 1300 and adjust the schedule to administer daily at 1300. This approach ensures that the client receives the correct total daily dose of levofloxacin. Choice A is incorrect because contacting the healthcare provider and completing a medication variance form would not address the immediate need to administer the missed dose. Choice B is incorrect as administering the missed dose at 1300 and resuming the 0900 schedule the next morning would result in a missed dose for that day. Choice C is not the best course of action as notifying the charge nurse and completing an incident report should come after addressing the immediate need to administer the missed dose and adjusting the schedule for future doses.

5. What are the correct steps used for abdominal assessment?

Correct answer: A

Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection allows the nurse to visually assess the abdomen for any abnormalities or distension. Auscultation follows to listen for bowel sounds and vascular sounds. Percussion helps to assess the density of underlying structures and detect any abnormal masses. Palpation is performed last to assess tenderness, organ size, and detect any masses. Choices B, C, and D have the steps in the incorrect order, making them the wrong choices.

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