the nurse is assessing an immobile patient for deep vein thromboses dvts which action will the nurse take
Logo

Nursing Elites

HESI LPN

HESI Fundamentals Study Guide

1. The healthcare provider is assessing an immobile patient for deep vein thromboses (DVTs). Which action will the healthcare provider take?

Correct answer: B

Rationale: The correct action when assessing an immobile patient for deep vein thromboses (DVTs) is to measure the calf circumference of both legs. This helps in detecting swelling or changes that may indicate the presence of a DVT. Removing elastic stockings every 4 hours (Choice A) is not necessary and can disrupt circulation. Lightly rubbing the lower leg for redness and tenderness (Choice C) can potentially dislodge a clot if present. Dorsiflexing the foot while assessing for patient discomfort (Choice D) is not a specific assessment for DVT and may not provide relevant information in this context.

2. A client with a history of congestive heart failure (CHF) is admitted with dyspnea and a productive cough. What is the most important assessment for the LPN/LVN to perform?

Correct answer: B

Rationale: Auscultating lung sounds is crucial for assessing the extent of congestion in a client with CHF. The presence of crackles or wheezing can indicate fluid accumulation in the lungs, a common complication of CHF. Monitoring urine output (Choice A) is important to assess renal function but is not the priority in this situation. While assessing the apical pulse (Choice C) and checking blood pressure (Choice D) are important in managing CHF, they do not provide immediate information about the respiratory status and congestion level in the lungs, making auscultating lung sounds the most critical assessment.

3. When reviewing a client’s fluid and electrolyte status, what should the nurse report to the provider?

Correct answer: A

Rationale: The correct answer is A: 'Potassium 5.4'. A potassium level of 5.4 is elevated (normal range is typically 3.5-5.0 mEq/L) and may indicate hyperkalemia, which can have serious cardiac implications. Elevated potassium levels can lead to life-threatening arrhythmias, so immediate reporting and intervention are necessary. Choice B, 'Sodium 140', falls within the normal range (135-145 mEq/L) and does not require immediate reporting. Choice C, 'Calcium 8.6', falls within the normal range (8.5-10.5 mg/dL) and is not an immediate concern. Choice D, 'Magnesium 2.0', is within the normal range (1.5-2.5 mEq/L) and does not need urgent reporting. Therefore, the nurse should prioritize reporting the elevated potassium level as it poses the most immediate risk.

4. A client is being taught how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands?

Correct answer: B

Rationale: The correct answer is B. Gently applying pressure to the front part of the ear after administering drops helps with absorption. Pulling the ear down and back is a correct technique for adults. Snugly inserting the nozzle of the ear drop bottle or placing a cotton ball all the way into the ear canal is unnecessary and can potentially cause harm or discomfort. Therefore, choices A, C, and D are incorrect.

5. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

Correct answer: D

Rationale: Neuroblastoma, a common solid tumor in children, often presents with symptoms related to the mass effect it causes. Abdominal mass and weakness are classic signs of neuroblastoma due to the tumor originating in the adrenal glands near the kidneys and potentially compressing nearby structures. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more common in conditions affecting the central nervous system rather than neuroblastoma. Headaches and vomiting (Choice C) are nonspecific symptoms and are less commonly linked to neuroblastoma compared to the characteristic abdominal findings.

Similar Questions

A client with Parkinson's disease is being discharged. Which statement by the client indicates a need for further teaching?
A client with osteoporosis is prescribed alendronate (Fosamax). What instruction should the LPN/LVN provide to the client?
A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?
What intervention can help prevent atelectasis and pneumonia in a client with amyotrophic lateral sclerosis?
During assessment, what is a nurse monitoring when assessing body alignment?

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