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Lpn hesi fundamentals exam(wgu)
Total Questions : 60
Showing 10 questions, Sign in for moreA male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?
A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?
A 75-year-old male presents to the emergency department (ED) with poorly controlled diabetes. He had been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. The client was stabilized in the ED and transferred to the medical unit for continued stabilization and management. The client has a history of smoking and has smoked one pack per day for the past 40 years. There is a history of moderate obesity, insulin dependent diabetes, and mobility issues. He requires the use of a walker for mobility.
The client is moved from the gurney to the medical bed and requires two people to assist. The nurse performs a functional assessment. The client reports neuropathy in bilateral hands and lower legs. His skin is moist. He reports the need to wear an incontinence brief due to occasional accidents of both urine and stool. He explains that it is difficult for him to be able to move quickly enough when he feels the urge to use the bathroom. At home where he lives alone, he reports spending most of his time in his recliner, though he can ambulate within the home and does so if needed. He does feel like he slides in bed to move because repositioning is difficult. He is currently using a front-wheeled walker. He reports difficulty eating a full meal and has less than optimal PO intake. Coarse lung sounds are noted.
1735
The perineal area is noted to have redness with no open sores. The client has blanchable redness noted on both heels bilaterally and on the coccyx.
1800
The nurse does a formal wound assessment on the coccyx noting non-blanchable redness that measures 0.9 in by 0.7 in 0 in (2.3 cm by 1.8 cm by 0 cm). The skin is intact and there is no drainage or purple discoloration noted.
1715
Vital signs and assessments
Temperature 98.7° F (37" C)
Heart rate 94 beats/minute
Respiratory rate 18 breaths/minute
Blood pressure 138/88 mm Hg
Oxygen saturation 95% on room air
Pain 3 on a 0 to 10 pain scale, baseline numbness and tingling in bilateral upper and lower extremities
Braden score is 13
|
Laboratory Test |
Result |
Reference Range |
|
Glucose |
180 mg/dL (10 mmol/L) |
74 to 106 mg/dL (4.1 to 5.9 mmol/L) |
1715
Capillary blood glucose before meals and bedtime
Patient Data
Explanation
Rationale for Correct Choices
- Pressure injury: The client has non-blanchable redness on the coccyx with intact skin, indicating a Stage 1 pressure injury. Risk factors include limited mobility, obesity, neuropathy, incontinence, and poor nutrition, making prevention and early intervention critical.
- Offload coccyx and other bony prominences: Relieving pressure is essential to prevent further tissue damage. This includes repositioning the client at least every two hours and using support surfaces such as foam wedges or specialized mattresses.
- Cleanse and dress wound: Maintaining skin integrity and hygiene prevents infection. Gentle cleansing and application of a protective dressing reduces friction, moisture, and bacterial colonization on the affected area.
- Wound status: Monitoring wound characteristics such as size, color, and drainage ensures that interventions are effective and allows early detection of deterioration or infection.
- Documentation of skin prevention measures: Recording interventions, repositioning schedules, and skin assessments helps evaluate adherence to the prevention plan and communicates continuity of care among the healthcare team.
Rationale for Incorrect Choices
- Elder abuse: While vulnerability exists, there is no evidence of physical trauma or neglect; the findings are consistent with pressure-related injury from immobility rather than external harm.
- Altered nutrition: Although the client has suboptimal intake and weight concerns, nutrition alone does not explain the presence of localized non-blanchable redness; this is primarily a pressure injury issue.
- Bowel obstruction: The client reports occasional incontinence but no vomiting, abdominal distension, or absent bowel sounds. These signs do not suggest obstruction, making this an unlikely acute concern.
- Administer an enema: The client’s incontinence and skin findings do not indicate constipation or impaction requiring immediate enemas. This action would not address the pressure injury.
- Contact adult protective services: There is no indication of neglect or abuse at home; intervention should focus on skin care and prevention rather than protective services.
- Immediately begin a bowel training program: Bowel management is important for incontinence but is not the immediate priority. The client’s acute skin compromise requires urgent offloading and wound care first.
- Vital signs: While monitoring vital signs is standard, they do not directly reflect the progression or improvement of the pressure injury, so this is secondary for assessing this condition.
- Family dynamics: The client lives alone and the issue is primarily related to physical risk factors. Monitoring family interactions does not provide immediate information about the wound or skin integrity.
- Incontinence episodes: Tracking incontinence is relevant for prevention planning but does not assess the current injury or healing status, making it less critical than wound monitoring and documentation.
An older adult woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client's teaching plan?
The nurse uses a sterile syringe to obtain a urine specimen from a client's indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the laboratory. During which part of this procedure should the nurse wear gloves?
While measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. Which follow- up action should the nurse take first?
Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?
A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client's axilla. Which action should the nurse take?
When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?
The nurse is documenting wound care in a client's electronic medical record (EMR) when the computer system shuts down. Which action should the nurse implement first?
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