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Exam (elaborations)

PN HESI Exit V2

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Exam of 49 pages for the course PN HESI at PN HESI (PN HESI Exit V2)

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HESI PN EXIT EXAM V2

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PN HESI Exit V2


1) 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?

1. Provide the client with a walker.
2. Remove the telemetry equipment.
3. Encourage the client to cough and deep breathe.
4. Premedicate the client with an analgesic before ambulating.

Correct Answer: 4. Premedicate the client with an analgesic before
ambulating.


2) 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?


1. Call a code blue.
2. Call the health care provider.
3. Check the client status and lead placement.
4. Press the recorder button on the ECG console.

Correct Answer: 3. Check the client status and lead placement.


3) 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 expects which
interventions to be prescribed? Select all that apply.


1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit




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6. Placing the client in a low-Fowler's side-lying position

Correct Answer:
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)


4) The nurse is monitoring a client following cardioversion. Which
observations should be of highest priority to the nurse?


Blood pressure
Status of airway
Oxygen flow rate
Level of consciousness

Correct Answer: 2. Status of airway

5) 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 dislodgement of the pacing
catheter by implementing which intervention?


Limiting movement and abduction of the left arm
Limiting movement and abduction of the right arm
Assisting the client to get out of bed and ambulate with a walker
Having the physical therapist do active range of motion to the right
arm

Correct Answer: 2. Limiting movement and abduction of the right arm

6) 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?


1. Pneumonia




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2. Pulmonary edema
3. Pulmonary embolism
4. Myocardial infarction

Correct Answer: 3. Pulmonary embolism


7) 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?


Smoking history
Recent exposure to allergens
History of recent insect bites
Familial tendency toward peripheral vascular disease

Correct Answer: 1. Smoking history

8) The nurse has reinforced instructions to the client with
Raynaud's disease about self-management of the disease process.
The nurse determines that the client needs further teaching if the
client states which?


"Smoking cessation is very important."
"Moving to a warmer climate should help."
"Sources of caffeine should be eliminated from the diet."
"Taking nifedipine (Procardia) as prescribed will decrease vessel
spasm."

Correct Answer: 2. "Moving to a warmer climate should help."


9) A client with myocardial infarction suddenly becomes tachycardic,
shows signs of air hunger, and begins coughing frothy, pink-tinged
sputum. The nurse listens to breath sounds, expecting to hear which
breath sounds bilaterally?




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