the nurse is assessing an immobile patient for deep vein thromboses dvts which action will the nurse take
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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 is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?

Correct answer: B

Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.

3. A client diagnosed with a terminal illness asks the nurse about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:

Correct answer: B

Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse’s beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.

4. The nurse is caring for a 17-month-old child with acetaminophen poisoning. Which laboratory reports should the nurse review first?

Correct answer: D

Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the drug's metabolism in the liver. Monitoring liver enzymes such as AST and ALT is crucial as they indicate liver function and damage. Prothrombin time (PT) and partial thromboplastin time (PTT) (Choice A) are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts (Choice B) are not directly related to acetaminophen poisoning. Blood urea nitrogen and creatinine levels (Choice C) assess kidney function, but liver enzymes are more specific for evaluating liver damage in acetaminophen poisoning.

5. The patient diagnosed with diabetes is reporting severe foot pain due to corns and has been using oval corn pads to self-treat the corns. Which information will the nurse share with the patient?

Correct answer: C

Rationale: The nurse should inform the patient that using oval corn pads can increase pressure on the toes and impede circulation, which may exacerbate foot problems in patients with diabetes. It is important to avoid practices that restrict blood flow to the feet, as poor circulation can lead to serious complications. Soaking the feet and using a pumice stone can be beneficial for corns, but in this case, the current self-treatment with corn pads is not recommended. Tighter shoes would further increase pressure on the corns and should be avoided. Therefore, the nurse should emphasize the importance of proper foot care and recommend alternative treatments to promote foot health and prevent complications.

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