while changing the linen on the clients bed the nurse should
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Nursing Elites

HESI LPN

HESI Fundamentals Test Bank

1. While changing the linen on the client's bed, what should the nurse do?

Correct answer: A

Rationale: When changing the linen on a client's bed, it is essential for the nurse to hold the linen away from their body and clothing. This practice helps prevent contamination and maintain a clean environment. Folding the linen neatly before placing it in the laundry (Choice B) is a good practice but not the immediate action required during linen changing. Wearing clean gloves while handling the linen (Choice C) is important in certain situations but may not be necessary for routine linen changing. Placing the linen directly on the floor until the new linen is in place (Choice D) is incorrect as it can lead to contamination and is not hygienic.

2. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client’s wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.

3. A client recovering from lung cancer is advised to resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Correct answer: A

Rationale: The correct answer is A: Washing dishes. Washing dishes is a lower-intensity activity that is suitable for a client recovering from lung cancer. This activity does not require significant physical exertion and allows the client to engage in a manageable task while still following the provider's instructions for lower-intensity activities. Choices B, C, and D involve more physical effort and may not be appropriate for a client recovering from lung cancer, as they require more energy and physical strain, which could hinder the recovery process.

4. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Correct answer: C

Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.

5. A client with osteoporosis is prescribed alendronate (Fosamax). What instruction should the LPN/LVN provide to the client?

Correct answer: A

Rationale: The correct instruction for a client prescribed alendronate (Fosamax) is to take the medication with a full glass of water. Alendronate can cause irritation to the esophagus, so it is important to take it with a full glass of water and remain upright for at least 30 minutes after taking the medication to help prevent this irritation. Taking the medication at bedtime (choice B) may increase the risk of esophageal irritation as lying down can allow the medication to remain in the esophagus longer. Taking the medication with food (choice C) or on an empty stomach (choice D) can also interfere with the absorption of alendronate, reducing its effectiveness in treating osteoporosis.

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