the nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place what should the nurse do to prevent skin impairme
Logo

Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. The patient has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment?

Correct answer: A

Rationale: To prevent skin impairment in a patient with a cast, the nurse should assess surfaces exposed to the edges of the cast for pressure areas. This is important to prevent pressure ulcers or skin breakdown. Keeping the patient's blood pressure low (Choice B) is not directly related to preventing skin impairment in this scenario. Allowing turning in bed (Choice C) is essential for preventing complications like pressure ulcers and is not contraindicated. Encouraging the patient's dietary intake (Choice D) to maintain hydration is not directly related to preventing skin impairment associated with a cast.

2. When teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses, what should the charge nurse instruct as the initial response in CPR?

Correct answer: A

Rationale: The correct initial response in CPR is to confirm unresponsiveness. This step is crucial to ensure that the person actually needs CPR before proceeding with further actions. Checking for unresponsiveness is essential to determine if the individual is in need of immediate assistance. Checking for a pulse or beginning chest compressions without confirming unresponsiveness could waste valuable time and potentially harm the individual. Calling for emergency help is important, but it should follow the confirmation of unresponsiveness to ensure timely activation of emergency services.

3. A client requires rectal temperature monitoring, and a nurse has a thermometer with a long, slender tip at the bedside. What is the appropriate action for the nurse to take?

Correct answer: A

Rationale: When monitoring rectal temperature, it is crucial to use a thermometer with a short, blunt insertion end to prevent injury and ensure accurate readings. Using a thermometer with a long, slender tip can pose a risk of perforation or discomfort for the client. Therefore, the appropriate action for the nurse to take is to obtain a thermometer with a short, blunt insertion end. Using the available thermometer as is would not address the safety concerns. Requesting a new thermometer is unnecessary when a suitable one is available by just obtaining it. Measuring the temperature orally instead would not provide the required rectal temperature monitoring.

4. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Correct answer: A

Rationale: A bounding pulse is indicative of fluid volume excess. In this case, the client's weight gain and edematous ankles already suggest fluid volume overload. A bounding pulse occurs due to increased blood volume and pressure. Choices B, C, and D are not indicative of fluid volume excess. Decreased blood pressure, dry mucous membranes, and weak pulse are more commonly associated with conditions such as dehydration or hypovolemia, where there is a decrease in fluid volume rather than an excess.

5. A healthcare provider is assessing a client with a diagnosis of acute pancreatitis. Which laboratory value would be most concerning?

Correct answer: D

Rationale: In acute pancreatitis, hypocalcemia (low serum calcium) is a critical finding that is associated with a poor prognosis and requires immediate attention. Serum amylase and lipase are typically elevated in acute pancreatitis due to pancreatic inflammation, but they are not indicators of severity. Blood glucose levels may be elevated due to stress or underlying conditions but are not directly related to the severity of acute pancreatitis. Therefore, the most concerning value in this scenario is the low serum calcium level, which can have significant implications for the client's prognosis.

Similar Questions

A healthcare professional is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the healthcare professional:
When reviewing car seat use with the parents of a 1-month-old infant, which of the following instructions should the nurse include?
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is
A client is receiving total parenteral nutrition (TPN). The nurse should monitor the client for which complication?

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