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. To use the nursing process correctly, what must the nurse do first?

Correct answer: A

Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.

3. 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.

4. A nurse is reviewing evidence-based practice principles about the administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Correct answer: A

Rationale: The correct answer is A. Regulating oxygen flow at no more than 6 L/min via nasal cannula is a safe practice to prevent potential complications such as oxygen toxicity. Option B suggesting administering oxygen at a higher flow rate for better saturation is incorrect as it can lead to adverse effects. Option C is incorrect because using a high-flow nasal cannula for all clients is not necessary and should be based on individual client needs. Option D is incorrect as adjusting oxygen flow solely based on client comfort without considering the prescribed flow rate can compromise the effectiveness of oxygen therapy.

5. A client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

Correct answer: B

Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.

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