which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind
Logo

Nursing Elites

HESI LPN

Medical Surgical HESI

1. Which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind?

Correct answer: B

Rationale: The correct answer is to speak to the client each time the nurse enters the room. This intervention is crucial for orienting and reassuring the client, promoting safety, and facilitating communication. Keeping the room well-lit (Choice A) can be helpful but is not as essential as direct verbal communication. Ensuring the client wears glasses (Choice C) may not be feasible or necessary for someone who is legally blind. Providing written instructions in large print (Choice D) is not effective for a client with visual impairments.

2. Following a bout of diarrhea, which foods should be offered to the school-age child?

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

3. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?

Correct answer: B

Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.

4. A client with partial-thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?

Correct answer: B

Rationale: Administering an analgesic before whirlpool therapy is the priority intervention in this scenario. Whirlpool therapy for debridement can be painful for the client with partial-thickness burns. Administering an analgesic before the procedure helps manage pain during the debridement process, ensuring the client's comfort. Applying a sterile dressing (Choice A) may be necessary after the whirlpool therapy but is not the immediate pre-transport intervention. Encouraging the client to drink fluids (Choice C) and ensuring nutritional needs are met (Choice D) are important aspects of care but are not specifically related to preparing the client for whirlpool therapy.

5. The client with chronic venous insufficiency is being taught about self-care measures. Which instruction should be included?

Correct answer: B

Rationale: The correct instruction for a client with chronic venous insufficiency is to elevate their legs above heart level when resting. This position helps reduce venous pressure and edema, improving circulation. Avoiding compression stockings (choice A) is incorrect as they are beneficial in managing chronic venous insufficiency. Applying heat packs (choice C) is not recommended as heat can worsen edema. Limiting walking (choice D) is not advisable as regular, gentle exercise like walking can actually help improve circulation in patients with chronic venous insufficiency.

Similar Questions

When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?
A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?
Which signs/symptoms would be considered classical signs of meningeal irritation?
The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
An adolescent female asks the nurse about taking retinoic acid (Accutane). What guidance should be provided by the nurse?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses