HESI COMPREHENSIVE REVIEW NCLEX-PN EXAMINATION 5TH EDITION 2023 COMPLETE QUESTIONS WITH VERIFIED ANSWERS | RATED A+

HESI COMPREHENSIVE REVIEW NCLEX-PN EXAMINATION 5TH EDITION 2023 COMPLETE QUESTIONS WITH VERIFIED ANSWERS | RATED A+ An elderly female client calls the clinic and states that she feels very weak and dizzy. Further assessment by the practical nurse (PN) indicates that the client self-administered an enema of 3 liters of tap water because she felt constipated. What is the most likely cause of the client's symptoms? A. Mucosal bleeding B. Sodium retention C. Fluid volume depletion D. Water intoxication - AnswerD. Water Intoxication Rationale: Tap water is a hypotonic fluid, which can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication (D). This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause mucosal irritation, which might result in some bleeding (A), but the client would not experience weakness and dizziness unless she were hemorrhaging. (B and C) can occur with the use of hypertonic, rather than hypotonic, solutions. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement should the practical nurse (PN) identify that best demonstrates the client's readiness to manage his wound care after discharge? A. The client asks relevant questions regarding the dressing change. B. The client states that he will be able to complete the wound care regimen. C. The client demonstrates the wound care procedure correctly. D. The client has all the necessary supplies for wound care. - AnswerC. The client demonstrates the wound care procedure correctly. Rationale: A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, whereas (A and B) are subjective measures. (D) is important but is of less priority before discharge than the practical nurse's assessment of the client's ability to complete the wound care. The practical nurse (PN) is applying the finger probe for continuous pulse oximetry on a client. Which actions should help prevent skin irritation or breakdown? (Select all that apply.) A. Rotate the probe location site every 4 to 8 hours. B. Remove fingernail polish with acetone. C. Cleanse with soap and water as needed. D. Secure with gauze if client has allergy to adhesives. E. Apply lotion before attaching the probe. - AnswerA,C, and D Rationale: Site rotation (A), skin cleansing (C), and avoidance of adhesives for allergies (D) should help prevent skin irritation or breakdown. Removing fingernail polish will not help prevent skin irritation (B), and application of lotion will not help prevent skin irritation or breakdown (E). A 65-year-old client who attends an adult day care program and is wheelchair-mobile has redness in the sacral area. Which information is most important for the practical nurse (PN) to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other fluids. D. Purchase a newer model wheelchair. - AnswerB. Change positions in the chair at least every hour. Rationale: The most important teaching is to change positions frequently (B) because pressure is the most significant factor related to the development of pressure ulcers. (A and C) may be beneficial as well to promote healing and to reduce further risk. (D) is an intervention of last resort because this will be very expensive for the client.