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Exam (elaborations)

HESI PN FUNDAMENTALS V1 EXAM

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1. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement? - Give an around-the-clock schedule for administration of analgesics. 2. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? - Loosen the right wrist restraint. 3. The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? - A lactating woman nursing her 3-day-old infant. 4. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? - Give the missed dose at 1300 and change the schedule to administer daily at 1300. 5. While instructing a male client's wife in the performance of passive rangeof-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? - Acknowledge that she is supporting the arm correctly 6. What is the most important reason for starting intravenous infusions in theupper extremities rather than the lower extremities of adults? - A decreased flow rate could result in the formation of a thrombosis 7. The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? - Reassess the client's blood pressure using a larger cuff 8. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion? - 150 ml/hr 9. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN - The body's receptors adapt over time as they are exposed to heat 10. The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? - I will limit my intake of beef to 4 ounces per week 11. The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? - Move the chair parallel to the right side of the bed, and stand the client onthe right foot

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Uploaded on
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