the nurse assesses an older adult who is newly admitted to a long term care facility the client has dry flaky skin and long thickened fingernails the
Logo

Nursing Elites

HESI LPN

HESI CAT

1. The nurse assesses an older adult who is newly admitted to a long-term care facility. The client has dry, flaky skin and long thickened fingernails. The client has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)?

Correct answer: A

Rationale: Soaking and filing fingernails is a task that can be delegated to UAP. This task does not require specialized nursing skills and can be safely performed by unlicensed personnel. Offering fluids frequently, monitoring skin elasticity, and ambulating require more skilled assessments and interventions, which are responsibilities of the nurse. The client's dry, flaky skin and long thickened fingernails indicate the need for basic hygiene care, making it appropriate for delegation to unlicensed personnel.

2. When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?

Correct answer: C

Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.

3. In what sequence should the nurse prepare the dose of insulin for a client whose finger stick glucose is 210 mg/dl and is receiving a sliding scale dose of short-acting insulin before breakfast?

Correct answer: A

Rationale: The correct sequence for preparing a dose of insulin involves ensuring proper aseptic technique. First, clean the vial's rubber stopper with an alcohol swab to prevent contamination. Second, withdraw the correct dose of insulin to be administered. Lastly, inject air equal to the insulin dose into the vial to maintain proper pressure for withdrawing the medication. This sequence ensures the medication is prepared safely and accurately. Choice A is correct as it follows this sequence. Choices B, C, and D present incorrect sequences that may compromise patient safety by not following the correct aseptic technique. Choice B injects air into the vial before withdrawing insulin, which is incorrect. Choice C reverses the order of withdrawing insulin and injecting air. Choice D withdraws the insulin before injecting air, which can affect the pressure inside the vial and lead to inaccurate dosing.

4. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client’s statements?

Correct answer: C

Rationale: The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.

5. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

Correct answer: C

Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.

Similar Questions

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that her voices are saying, “Kill, Kill.” What question should the nurse ask the client next?
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?
A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
Which behavior is most likely to result in a breach of client confidentiality?
What nursing intervention is most important to implement after a client has completed a myelogram?

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