HESI Exit V2 The Second Versi on The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? - The Correct Answer is --Premedicate the client with an analgesic before ambulating . A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? - The Correct Answer is --Check the client status and lead placemen t. The LPN/LVN in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expec ts which interventions to be prescribed? Select all that apply. - The Correct Answer is --1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) The nurse is monitoring a client following cardioversion. Which observation s should be of highest priority to the nurse? - The Correct Answer is --Status of airway The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodge ment of the pacing catheter by implementing which intervention? - The Correct Answer is --
Limiting movement and abduction of the right arm A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The LPN/LVN understands that a life -threatening complication of this condition is which? - The Correct Answer is --
Pulmonary embolism A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? - The Correct Answer is --Smoking history The nurse has reinforced instructions to the client with Raynaud's disease about self -
mana gement of the disease process. The nurse determines that the client needs further teaching if the client states which? - The Correct Answer is --"Moving to a warmer climate should help." A client with myocardial infarction suddenly becomes tachycardic, sh ows signs of air hunger, and begins coughing frothy, pink -tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? - The Correct Answer is --
Crackles The LPN/LVN is collecting data on a client with a diagnosis of right - sided heart failure. The nurse should expect to note which specific characteristic of this condition? - The Correct Answer is --Dependent edema The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing uni t 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? - The Correct Answer is --Normal, caused by increased blood flow through the leg A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may s timulate which? - The Correct Answer is --Vagus nerve to slow the heart rate A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection? - The Correct Answer is --
Staphyloco ccal infection client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? - The Correct Answer is --The boot has been applied too tightly A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain? - The Correct Answer is --Variant angina The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? - The Correct Answer is --Hyperactive bowel sounds in the area An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that —my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? - The Correct Answer is --Denial A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure? - The Correct Answer is --Prior reaction to contrast media A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? - The Correct Answer is --Caffeine An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Wh ich question best assists the nurse to discriminate pain caused by a non cardiac problem? - The Correct Answer is --
"Does the pain get worse when you breathe in?" A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? - The Correct Answer is --Bathroom privileges and self -care activities The LPN/LVN is pr eparing to care for a client who will be arriving from the recovery room after an above -the-knee amputation. The nurse ensures that which priority item is available for emergency use? - The Correct Answer is --Surgical tourniquet A client is diagnosed wit h thrombophlebitis. The nurse should tell the client that which prescription is indicated? - The Correct Answer is --Bed rest, with elevation of the affected extremity A client returns to the nursing unit after an above knee amputation of the right leg. I n which position should the nurse place the client? - The Correct Answer is --With the foot of the bed elevated The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? - The Correct Answer is --Bilberry
Limiting movement and abduction of the right arm A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The LPN/LVN understands that a life -threatening complication of this condition is which? - The Correct Answer is --
Pulmonary embolism A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? - The Correct Answer is --Smoking history The nurse has reinforced instructions to the client with Raynaud's disease about self -
mana gement of the disease process. The nurse determines that the client needs further teaching if the client states which? - The Correct Answer is --"Moving to a warmer climate should help." A client with myocardial infarction suddenly becomes tachycardic, sh ows signs of air hunger, and begins coughing frothy, pink -tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? - The Correct Answer is --
Crackles The LPN/LVN is collecting data on a client with a diagnosis of right - sided heart failure. The nurse should expect to note which specific characteristic of this condition? - The Correct Answer is --Dependent edema The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing uni t 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? - The Correct Answer is --Normal, caused by increased blood flow through the leg A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may s timulate which? - The Correct Answer is --Vagus nerve to slow the heart rate A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection? - The Correct Answer is --
Staphyloco ccal infection client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? - The Correct Answer is --The boot has been applied too tightly A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain? - The Correct Answer is --Variant angina The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? - The Correct Answer is --Hyperactive bowel sounds in the area An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that —my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? - The Correct Answer is --Denial A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure? - The Correct Answer is --Prior reaction to contrast media A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? - The Correct Answer is --Caffeine An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Wh ich question best assists the nurse to discriminate pain caused by a non cardiac problem? - The Correct Answer is --
"Does the pain get worse when you breathe in?" A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? - The Correct Answer is --Bathroom privileges and self -care activities The LPN/LVN is pr eparing to care for a client who will be arriving from the recovery room after an above -the-knee amputation. The nurse ensures that which priority item is available for emergency use? - The Correct Answer is --Surgical tourniquet A client is diagnosed wit h thrombophlebitis. The nurse should tell the client that which prescription is indicated? - The Correct Answer is --Bed rest, with elevation of the affected extremity A client returns to the nursing unit after an above knee amputation of the right leg. I n which position should the nurse place the client? - The Correct Answer is --With the foot of the bed elevated The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? - The Correct Answer is --Bilberry
