the unlicensed assistive personnel uap reports to the nurse that a client refused to bathe for the third consecutive day what action is best for the n
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Nursing Elites

HESI LPN

Adult Health 2 Final Exam

1. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?

Correct answer: A

Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.

2. Which nonfood item is the most common cause of respiratory arrest in young children?

Correct answer: D

Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.

3. What is the most important information the nurse should teach a diabetic client about foot care?

Correct answer: A

Rationale: The correct answer is to inspect feet daily. For diabetic clients, daily foot inspection is crucial in preventing complications like infections and ulcers. By checking their feet regularly, clients can identify any issues early and seek appropriate medical care. The other choices are important aspects of foot care for diabetic clients but not as critical as daily foot inspections. Wearing cotton socks helps in moisture control, using lukewarm water to wash feet helps prevent skin damage, and cutting nails straight across prevents ingrown nails. However, daily foot inspection is the most vital as it allows for early detection of any potential problems, which is key in diabetic foot care.

4. The nurse is teaching a client with hypertension about lifestyle modifications. Which recommendation is most effective for lowering blood pressure?

Correct answer: B

Rationale: Engaging in regular physical activity is a highly effective recommendation for lowering blood pressure and improving overall cardiovascular health. Regular exercise helps to strengthen the heart, improve blood circulation, and manage weight, all of which contribute to reducing blood pressure levels. Choices A, C, and D are incorrect. Increasing intake of red meat can lead to higher saturated fat consumption, which is detrimental to heart health. Consuming a high-sodium diet can exacerbate hypertension by increasing blood pressure. Limiting fluid intake to 1 liter per day may lead to dehydration and is not a recommended approach for managing hypertension.

5. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?

Correct answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye. Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

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