PN Fundamental Hesi V1

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. 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. 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. 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. 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 What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? - A decreased flow rate could result in the formation of a thrombosis 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 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 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 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 ) 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 on the right foot An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP? - Reposition in a Sim's position with the client's weight on the anterior ilium. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs? - Blood transfusions are forbidden The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? - Observe the appearance of the skin under the ice pack The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? - 124 gtt/min ) A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the LPN/LVN to take? - After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the LPN advise the client to follow? - 8 a.m., 4 p.m., and midnight A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump? - 63 ml/hour An obese male client discusses with the LPN/LVN his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? - Be sure to have a complete physical examination before beginning your planned exercise program. The LPN is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? - . During the inhalation. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the LPN/LVN plan to administer? - 1½ tablets. hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer? - 1.5 ml. Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? - 11,000 units. The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer? - . 0.5 ml. The LPN prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute - 21 Which action is most important for the LPN/LVN to implement when donning sterile gloves? - Keep gloved hands above the elbows A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the LPN/LVN to take? - Measure the pulse volume and capillary refill distal to the infiltration. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings - . Fowler's. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan? - Place a pillow between your knees while lying in bed to prevent hip dislocation.