HESI Exit V2

HESI Exit V2 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? - 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? - 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. - 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? - 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? - ANSWER Limiting 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? - ANSWER Pulmonary 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? - 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? - 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? - ANSWER Crackles 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? - 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? - 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? - 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? - ANSWER Staphylococcal 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? - 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? - ANSWER Variant angina The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? - 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? - 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? - 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? - ANSWER Caffeine An ambulatory clinic nurse is interviewing a client who is c