the pn observes a uap bathing a bedfast client with the bed in the high position which action should the pn take
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Nursing Elites

HESI LPN

HESI PN Exit Exam

1. The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?

Correct answer: D

Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern. Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety. Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP. Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.

2. A client with uterine cancer asks the nurse, 'Which is the most common type of cancer in women?' The nurse replies that it is breast cancer. Which type of cancer causes the most deaths in women?

Correct answer: B

Rationale: Lung cancer is the leading cause of cancer-related deaths in women, surpassing even breast cancer. While breast cancer is more common, it is often detected early enough for effective treatment. Lung cancer, on the other hand, tends to be diagnosed at later stages, leading to higher mortality rates. Brain cancer and colon and rectal cancer are not the leading causes of cancer-related deaths in women, making them incorrect choices.

3. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?

Correct answer: A

Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.

4. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

5. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?

Correct answer: B

Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.

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