the nurse is assigned to administer medications in a long term care facility a disoriented resident has no identification band or picture what is the
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Nursing Elites

HESI LPN

HESI PN Exit Exam

1. The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?

Correct answer: A

Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.

2. Which of the following factors increases the risk of developing a pressure ulcer?

Correct answer: C

Rationale: Immobility is a significant risk factor for pressure ulcers because it leads to prolonged pressure on specific areas of the body, reducing blood flow and leading to tissue breakdown. Choices A, B, and D are incorrect. A high-protein diet can actually aid in wound healing and tissue repair. Frequent repositioning helps relieve pressure on bony prominences, reducing the risk of pressure ulcers. Active range of motion exercises can improve circulation and prevent muscle atrophy, thereby reducing the risk of pressure ulcers.

3. When a woman in early pregnancy is leaving the clinic, she blushes and asks the nurse if it is true that sex during pregnancy is bad for the baby. What is the best response for the nurse to give?

Correct answer: D

Rationale: Choice D is the best response as it reassures the patient that intercourse in a normal pregnancy will not harm the baby. It also shows empathy by acknowledging that many women experience changes in sexual desire during pregnancy. This response validates the patient's concerns and opens up a dialogue about her feelings. Choice A is incorrect as it lacks information about changes in sexual desire and oversimplifies the situation. Choice B is dismissive of the patient's concerns and does not provide adequate information. Choice C is not the best response as it suggests asking the doctor without offering immediate reassurance or addressing the patient's worries.

4. What is the function of the epiglottis during swallowing?

Correct answer: A

Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.

5. Which type of isolation is required for a patient with measles?

Correct answer: B

Rationale: The correct answer is B: Airborne isolation. Measles is highly contagious and can be transmitted through airborne particles, so airborne isolation is necessary to prevent its spread. Choice A, Contact isolation, is incorrect because measles is not primarily transmitted through direct contact. Choice C, Droplet isolation, is also incorrect as measles is not transmitted through large droplets but through smaller airborne particles. Choice D, Reverse isolation, is used to protect a patient from outside infections, not to prevent the spread of a contagious disease like measles.

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