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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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. The clinician is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing?

Correct answer: D

Rationale: Applying a hydrocolloid or foam dressing is the most effective treatment to promote healing for a Stage 2 skin ulcer. These dressings create a moist environment that supports healing and prevents further tissue damage. Option A (covering the wound with a dry dressing) can lead to drying out the wound bed, hindering healing. Option B (using hydrogen peroxide soaks) can be too harsh and may damage the surrounding healthy tissue. Option C (leaving the area open to dry) can delay healing as it does not provide the necessary moist environment for optimal wound healing.

3. An 80-year-old client admitted with a diagnosis of a possible cerebral vascular accident has had a blood pressure ranging from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the healthcare provider?

Correct answer: A

Rationale: Slurred speech is a classic sign of a worsening stroke, suggesting a potential blockage or hemorrhage affecting speech centers in the brain. Prompt reporting of this symptom to the healthcare provider is crucial for immediate evaluation and intervention. While incontinence (Choice B) is important to monitor, it is not considered an immediate priority over slurred speech in this context. Muscle weakness (Choice C) and rapid pulse (Choice D) are also relevant in stroke assessment, but slurred speech takes precedence due to its strong association with neurological deficits in the setting of a possible cerebral vascular accident.

4. The LPN is instructing a client with high cholesterol about diet and lifestyle modifications. What comment from the client indicates that the teaching has been effective?

Correct answer: C

Rationale: The correct answer is C. Limiting intake of beef to 4 ounces per week is an effective dietary modification to manage high cholesterol. Choice A is incorrect because the frequency and duration of exercise alone may not be sufficient to lower cholesterol significantly. Choice B is incorrect as proteins, including lean sources like poultry and fish, can be a part of a healthy diet. Choice D is incorrect as low-density lipoproteins, known as bad cholesterol, should be decreased, not increased, for heart health.

5. A client has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

Correct answer: B

Rationale: The correct order of steps for this procedure is to first inject air into the NPH insulin bottle to prevent vacuum formation. After injecting air into the NPH insulin, the next step is to withdraw the correct dose of regular insulin from its bottle. This sequence ensures that the regular insulin is drawn after the NPH insulin, preventing contamination and ensuring accurate dosing. Therefore, choice B is correct. Choices A, C, and D are incorrect because air should be injected into the NPH insulin first, not the regular insulin, and the doses should be withdrawn in the appropriate order to maintain the integrity and potency of each insulin type.

Similar Questions

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