The healthcare professional caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for this action?

Questions 91

HESI LPN

HESI LPN Test Bank

HESI Practice Test for Fundamentals Questions

Question 1 of 5

The healthcare professional caring for a patient who is immobile frequently checks for impaired skin integrity. What is the rationale for this action?

Correct Answer: C

Rationale: The rationale behind checking for impaired skin integrity in an immobile patient is that pressure reduces circulation to the affected tissue. Prolonged pressure on specific body parts can lead to reduced blood flow to those areas, causing tissue damage and potentially leading to pressure ulcers. Choices A, B, and D are incorrect because inadequate blood flow causing decreased tissue ischemia, limited caloric intake leading to thicker skin, and decreased verbalization of skin care needs are not directly related to the rationale for checking for impaired skin integrity in immobile patients.

Question 2 of 5

A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?

Correct Answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

Question 3 of 5

An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:

Correct Answer: D

Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.

Question 4 of 5

During an initial history and physical assessment of a 3-month-old brought into the clinic for spitting up and excessive gas, what would the nurse expect to find?

Correct Answer: B

Rationale: Restlessness and increased mucus production are common signs of gastrointestinal issues or reflux in infants, which could explain the symptoms of spitting up and excessive gas. Increased temperature and lethargy (Choice A) are more indicative of an infection rather than gastrointestinal issues. Increased sleeping and listlessness (Choice C) are not typical signs associated with the symptoms described. Diarrhea and poor skin turgor (Choice D) are not directly related to the symptoms of spitting up and gas in this scenario.

Question 5 of 5

The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?

Correct Answer: D

Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.

Access More Questions!

HESI LPN Basic


$89/ 30 days

HESI LPN Premium


$150/ 90 days

Similar Questions