PN HESI EXI

PN HESI EXIT The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? 1. Tall, spiked T waves 2. A prolonged QT interval 3. A widening QRS complex 4. Presence of a U wave Correct Answer: 4. Presence of a U wave A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis? 1. "Before discharge, the client correctly identifies three potassium-rich food sources." 2. "The client knows the importance of consuming potassium-rich foods daily." 3. "Before discharge, the client knows which food sources are high in potassium." 4. "The client understands all complications of the disease process." Correct Answer: 1 "Before discharge, the client correctly identifies three potassium-rich food sources." The LPN/LVN is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next? 1. Initiate the urine stream 2. Separate the labia 3. Position the collection cup 4. Observe the urine Correct Answer: 2. Separate the labia A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg? 1. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. 2. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. 3. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. 4. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging. Correct Answer: 3. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound A client who returned from a cystoscopic examination complains of pain while attempting to void. Which intervention should a nurse suggest to ease the client's pain while attempting to void? 1. Drink plenty of fluids. 2. Pour water over the perineal area. 3. Run water in the bathroom sink. 4. Sit in a warm sitz bath. Correct Answer: 4 Sit in a warm sitz bath. A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what interventions should the nurse implement? 1. Maintain an oral airway suction equipment and oxygen at the bedside 2. Provide respiratory isolation precautions for visitors and staff 3. Provide emergency anti convulsant medication at the bedside 4. Maintain a quiet calm darkened environment Correct Answer: D. Maintain a quiet calm darkened environment The LPN/LVN is interviewing a client who is taking interferon- alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? 1. Recommend mental health counseling. 2. Review the medication actions and interactions. 3. Assess for the client's daily activity level. 4. Provide information regarding a support group. Correct Answer: 2. Review the medication actions and interactions. The nurse is collecting data on a 38-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find? 1. Vision changes 2. Absent deep tendon reflexes 3. Tremors at rest 4. Flaccid muscles Correct Answer: 1 Vision changes An elderly female client tells the nurse that she does not do regular Breast Self Examinations (BSE) because she is too old. The nurse's response to the client is based on what information? A. The incidence of breast cancer increases with age B. The client should have a health care provider do a breast exam at least once a year C. After age 70, breast cancer is less likely to occur D. The history of breast cancer in a family member is indicative of the need for BSE Correct Answer: A. The incidence of breast cancer increases with age Which content about self-care should the LPN/LVN include in the teaching plan of a female client who has genital herpes? (Select all that apply.) 1. Encourage annual physical and Pap smear. 2. Take antiviral medication as prescribed. 3. Use condoms to avoid transmission to others. 4. Warm sitz baths may relieve itching. 5. Use Nystatin suppositories to control itching. 6. Use a douche with weak vinegar solution to decrease itching. Correct Answer: 1. Encourage annual physical and Pap smear. 2. Take antiviral medication as prescribed. 3. Use condoms to avoid transmission to others. 4. Warm sitz baths may relieve itching The physician diagnoses leukemia in a child, age 4, who complains of being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the pathophysiology behind leukemia? 1. Ineffective airway clearance related to fatigue 2. Activity intolerance related to anemia 3. Imbalanced nutrition: More than body requirements related to lack of activity 4. Ineffective cerebral tissue perfusion related to central nervous system infiltration by leukemic cells. Correct Answer: 2 Activity intolerance related to anemia A client returns to the unit following a cardiac catheterization with a Femoral artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return? A. Pupil responses to light B. Pedal pulses C. Respiratory rate D. Peripheral mobility Correct Answer: B. Pedal pulses