which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage
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Nursing Elites

HESI LPN

HESI Fundamentals 2023 Test Bank

1. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

Correct answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

2. During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?

Correct answer: A

Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.

3. A client who is post-op following a partial colectomy has an NG tube set on low continuous suction. The client complains of a sore throat and asks when the NG tube will be removed. Which response by the nurse is appropriate at this time?

Correct answer: A

Rationale: The correct response is A: 'When the GI tract is working again, in about three to five days, the tube can be removed.' After a partial colectomy, the GI tract needs time to recover and start functioning properly. The NG tube is typically removed when peristalsis returns, indicating GI function restoration, which usually occurs within 3-5 days post-op. Choice B is incorrect because the removal of the NG tube is not solely based on nausea improvement. Choice C is incorrect as it provides a longer duration for tube removal than is usually necessary. Choice D is incorrect as the cessation of drainage alone does not dictate NG tube removal; the return of GI function is the primary indicator.

4. When using an open irrigation technique for a client's catheter, what action should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.

5. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?

Correct answer: B

Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.

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