in planning care for a client with a surgical wound healing by secondary intention the nurse can anticipate that the client will
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will:

Correct answer: A

Rationale: Wounds healing by secondary intention involve the gradual filling of the wound with granulation tissue, leading to a higher risk of infection due to prolonged exposure. This makes choice A the correct answer. Choices B and C are incorrect because wounds healing by secondary intention take longer to heal and often result in more pain compared to wounds healing by primary intention. Choice D is also incorrect as wounds healing by secondary intention usually require more frequent dressing changes to prevent infection and promote healing.

2. A healthcare professional is collecting a urine specimen for a client to test via urine dipstick to determine the urine's specific gravity. The healthcare professional knows the result will indicate the amount of:

Correct answer: A

Rationale: Specific gravity measures the concentration of solutes in the urine, reflecting the kidney's ability to concentrate or dilute urine. Choice B, bacteria in the urine, is incorrect because specific gravity does not measure bacterial presence. Choice C, pH level of the urine, is incorrect as it refers to the acidity or alkalinity of the urine, not its specific gravity. Choice D, glucose in the urine, is incorrect as specific gravity does not directly measure glucose levels in urine.

3. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.

4. A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?

Correct answer: B

Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').

5. During an admission assessment, a nurse is documenting a client's medication. Which of the following actions should the nurse take?

Correct answer: C

Rationale: During an admission assessment, compiling a list of the client's current medications is crucial for accurate documentation and planning. This information helps prevent medication errors, identify potential interactions, and ensure continuity of care. While counseling the client on medication adherence (Choice A) is important, it is not the primary action when documenting medications. Assessing the client for medication reactions (Choice B) is relevant for monitoring side effects but not the immediate focus during documentation. Evaluating the client's understanding of medications (Choice D) is essential for education but does not address the immediate need for compiling a list of current medications.

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