the patient is unable to move self and needs to be pulled up in bewhat will the nurse do to make this procedure safe
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Nursing Elites

HESI LPN

HESI Fundamentals Exam Test Bank

1. What will ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed?

Correct answer: D

Rationale: To ensure the safe movement of a patient who is unable to move and needs to be pulled up in bed, it is essential to use a friction-reducing device. This device helps reduce the risk of injury to both the patient and the healthcare provider by minimizing the effort required to reposition the patient. Placing a pillow under the patient's head and shoulders (Choice A) may provide comfort but does not address the safety concerns associated with moving the patient. Attempting to move the patient alone (Choice B) is not recommended as it can lead to injuries for both the patient and the healthcare provider. Placing the side rails in the up position (Choice C) may not directly contribute to the safe movement of the patient in this scenario.

2. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

Correct answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

3. A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

Correct answer: A

Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.

4. During the initial physical assessment of a newly admitted client with a pressure ulcer, an LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?

Correct answer: B

Rationale: The correct answer is B. Providing supportive nursing care, such as applying emollients and reinforcing the dressing on the pressure ulcer, meets the immediate needs of the client and is in line with legal and professional standards. Option A is incorrect because increasing activity may not be directly related to the immediate skin care needs of the client. Option C is incorrect as debridement might not be immediately necessary based on the initial assessment. Option D is incorrect as nurses are often authorized to initiate treatments within their scope of practice without waiting for healthcare provider prescriptions, especially for routine care like skin moisturization and dressing reinforcement.

5. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?

Correct answer: C

Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.

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