based on the documentation in the medical record which action should the nurse implement next
Logo

Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. Based on the documentation in the medical record, which action should the nurse implement next?

Correct answer: B

Rationale: The correct answer is to observe the mother breastfeeding her infant. This action is essential to ensure that the infant is feeding well and to assess maternal-infant bonding. Administering the rubella vaccine subcutaneously (Option A) is not the immediate priority in this scenario as assessing breastfeeding is more crucial. Calling the nursery for the infant's blood type result (Option C) is premature and not the next appropriate step, as it does not address the immediate needs of the newborn. Administering Vicodin one tablet for pain (Option D) is not indicated without further assessment or indication of pain, making it an incorrect choice at this time.

2. The nurse is caring for a client who is postoperative following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?

Correct answer: B

Rationale: Maintaining hip abduction with pillows is the most important intervention to prevent dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and prevents excessive internal rotation, which can lead to dislocation. Keeping the client in a low Fowler's position (Choice A) does not provide the necessary support and stability for the hip joint. While early ambulation (Choice C) is important for preventing complications such as blood clots and promoting circulation, it is not the most crucial intervention for preventing dislocation. Placing the client in a prone position (Choice D) can be harmful and increase the risk of dislocation.

3. How should the nurse respond to an older male client who states that his religion does not permit him to bathe daily?

Correct answer: C

Rationale: The correct response is to offer the client several choices of times to bathe during the day. This approach respects the client's religious beliefs while ensuring that hygienic practices are still maintained. By providing options, the nurse can work together with the client to find a solution that aligns with both his beliefs and his health needs. Choice A is incorrect because solely reviewing the importance of hygiene may not address the client's specific religious concerns. Choice B is inappropriate as it disregards the client's beliefs and autonomy. Choice D is not the best approach as it may come off as confrontational or dismissive of the client's beliefs, rather than working collaboratively to find a suitable solution.

4. What is the most important aspect of colostomy care to teach the client?

Correct answer: C

Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.

5. The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?

Correct answer: B

Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.

Similar Questions

A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour, 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?
The nurse is assessing a client with chronic liver disease. Which lab value is most concerning?
The client with a new colostomy is being taught about colostomy care. Which statement by the client indicates effective learning?
The nurse is assessing a client who has been receiving total parenteral nutrition (TPN) for several days. Which complication should the nurse monitor for?
What safety measure should be implemented when administering chemotherapy?

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