HESI Exit V2 DUE 31 OCTOBER 2023

HESI Exit V2 DUE 31 OCTOBER 2023 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? - CORRECT ANSWER-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? - CORRECT ANSWER-Check the client status and lead placement. 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. - CORRECT ANSWER-1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? - CORRECT ANSWER-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 dislodgement of the pacing catheter by implementing which intervention? - CORRECT ANSWERLimiting 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? - CORRECT ANSWERPulmonary 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? - CORRECT ANSWER-Smoking history The nurse has reinforced instructions to the client with Raynaud's disease about selfmanagement of the disease process. The nurse determines that the client needs further teaching if the client states which? - CORRECT ANSWER-"Moving to a warmer climate should help." 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? - CORRECT ANSWERCrackles The LPN/LVN is collecting data on a client with a diagnosis of rightsided heart failure. The nurse should expect to note which specific characteristic of this condition? - CORRECT ANSWER-Dependent edema The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing unit 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? - CORRECT ANSWER-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 stimulate which? - CORRECT ANSWER-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? - CORRECT ANSWERStaphylococcal 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? - CORRECT ANSWER-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? - CORRECT ANSWER-Variant angina The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? - CORRECT ANSWER-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? - CORRECT ANSWER-Denial A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure? - CORRECT ANSWER-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? - CORRECT ANSWER-Caffeine An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a non cardiac problem? - CORRECT ANSWER- "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? - CORRECT ANSWER-Bathroom privileges and self-care activities The LPN/LVN is preparing 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? - CORRECT ANSWER-Surgical tourniquet A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? - CORRECT ANSWER-Bed rest, with elevation of the affected extremity A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? - CORRECT ANSWER-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? - CORRECT ANSWER-Bilberry The LPN/LVN is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. - CORRECT ANSWER-2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. A client is at risk for developing disseminated intravascular coagulopathy (DIC). The LPN/LVN should become concerned with which fibrinogen level? - CORRECT ANSWER-90 mg/dL A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The LPN/LVN should take which action first? - CORRECT ANSWER-Assist the client to sit or lie down. The LPN/LVN notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? - CORRECT ANSWER-Reviews the intake and output records for the last 2 days A client brings the following medications to the clinic for a yearly physical. The LPN/LVN realizes which medication has been prescribed to treat heart failure? - CORRECT ANSWER-Digoxin (Lanoxin) 1. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? - CORRECT ANSWER-Restricting the client's potassium intake A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? - CORRECT ANSWERAntihypertensives The LPN/LVN finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"? - CORRECT ANSWER-"Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" The LPN/LVN is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? - CORRECT ANSWER-Shock A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the LPN/LVN ask the client first? - CORRECT ANSWER-"When was the last time you had your blood pressure checked? The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The LPN/LVN takes which action before surgery to address this risk? - CORRECT ANSWER-Marking the location of the pedal pulses on the right leg When preparing a client for a pericardiocentesis, which position does the LPN/LVN place the client in? - CORRECT ANSWER-Supine with the head of bed elevated at a 45- to 60- degree angle For a client diagnosed with pulmonary edema, the LPN/LVN establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? - CORRECT ANSWER-Using a bedside commode for stools The LPN/LVN is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? - CORRECT ANSWER-Place the client in high-Fowler's position. The LPN/LVN has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health? - CORRECT ANSWER-The ability to take an accurate pulse in either the wrist or neck The clinic nurse is obtaining cardiovascular data on a client. The LPN/LVN prepares to check the client's apical pulse and places the stethoscope in which position? - CORRECT ANSWER-At the midclavicular line at the fifth left intercostal space The LPN/LVN is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The LPN/LVN bases the response on which information? - CORRECT ANSWER-Deficient oxygenation to heart cells results in angina pectoris pain. The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? - CORRECT ANSWERRespirations and blood pressure A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? - CORRECT ANSWER-"I need to adhere to my dietary restrictions." The LPN/LVN is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? - CORRECT ANSWER-Lemonade The LPN/LVN is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? - CORRECT ANSWER-"Where is the pain located?" The LPN/LVN has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? - CORRECT ANSWER-"I should routinely use polyunsaturated oils in my diet." The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? - CORRECT ANSWER-Tall, peaked T waves The LPN/LVN is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? - CORRECT ANSWER-STsegment depression While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? - CORRECT ANSWER-"So you're saying that you want to talk to your health care provider?" The LPN/LVN reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? - CORRECT ANSWER-"I should avoid sitting in one position for long periods of time." A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The LPN/LVN interprets that the client is experiencing which type of angina? - CORRECT ANSWER-Stable The LPN/LVN is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching? - CORRECT ANSWER-"It is best to exercise once a week for an hour." The LPN/LVN is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? - CORRECT ANSWER-Prinzmetal's angina is generally treated with calcium channel blocking agents. The LPN/LVN working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? - CORRECT ANSWER-The pain has not been unrelieved by rest and nitroglycerin tablets. The LPN/LVN is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? - CORRECT ANSWER-"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? - CORRECT ANSWER-Weight gain of 2 to 3 pounds in a few days A client has experienced an episode of pulmonary edema. The LPN/ LVN determines that the client's respiratory status is improving if which breath sounds are noted? - CORRECT ANSWER-Crackles in the lung bases A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? - CORRECT ANSWER-Relief of apprehension The LPN/LVN is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? - CORRECT ANSWER-"I will take this medication every day." The LPN/LVN determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? - CORRECT ANSWER-"I will avoid walking for exercise." An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? - CORRECT ANSWER-Place the client on a cardiac monitor. The LPN/LVN is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client? - CORRECT ANSWER-Take in adequate daily fiber to prevent straining during a bowel movement. An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission? - CORRECT ANSWERChlorpropamide