Which assessment data reflects the need for nurses to include the problem, "Risk for falls," in a client's plan of care?

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HESI Fundamental Practice Exam Questions

Question 1 of 5

Which assessment data reflects the need for nurses to include the problem, "Risk for falls," in a client's plan of care?

Correct Answer: B

Rationale: The correct answer is B. The recent administration of opioid analgesics increases the risk for falls due to potential side effects such as sedation and dizziness. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk for falls. Choice C, stooped posture with an unsteady gait, may indicate an existing risk but does not directly reflect the need to include 'Risk for falls' in the care plan. Choice D, expressed feelings of depression, is important to address but is not directly associated with the risk for falls.

Question 2 of 5

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?

Correct Answer: A

Rationale: The correct intervention is to assist the client back to bed. A decrease in oxygen saturation while ambulating indicates hypoxemia, and the immediate priority is to stabilize oxygen levels. Returning the client to bed allows for rest and decreased oxygen demand, potentially preventing further desaturation. Encouraging continued ambulation (Choice B) may worsen the hypoxemia by increasing oxygen demand. Obtaining portable oxygen (Choice C) is essential but should not delay addressing the low oxygen saturation. Moving the oximetry probe (Choice D) may not address the underlying cause of decreased oxygen saturation and should not be the first intervention.

Question 3 of 5

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

Correct Answer: C

Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.

Question 4 of 5

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?

Correct Answer: B

Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.

Question 5 of 5

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by K¼bler-Ross. During which stage of grieving should the LPN/LVN primarily use nonverbal interventions?

Correct Answer: D

Rationale: Nonverbal interventions are primarily used during the acceptance stage according to K¼bler-Ross's theory of death and dying. During the acceptance stage, the individual is more likely to be reflective and less communicative, making nonverbal interventions more effective. Choices A, B, and C are incorrect because anger, denial, and bargaining are stages that precede the acceptance stage in K¼bler-Ross's model, where verbal communication and processing emotions play a more significant role.

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