HESI LPN

1. A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. What action should the nurse take?

• A. Explain that the medication may take time to show improvement in symptoms
• B. Withhold the medication and notify the healthcare provider
• C. Advise the client to undergo liver function tests
• D. Document the assessment findings in the electronic health record

Correct Answer: D

Rationale: In this scenario, the nurse's priority is to document the assessment findings in the electronic health record. This action is crucial for maintaining an accurate record of the client's health status and can provide valuable information for the healthcare team. Withholding medication or advising additional tests should only be done after consulting with the healthcare provider based on the documented assessment findings.

2. During a home visit, a client with a history of angina reports frequent headaches. The client recently started a new prescription for diltiazem, a calcium channel blocker. What action should the nurse take?

• A. Explain the importance of obtaining a blood sample promptly to test for medication toxicity
• B. Consult with the healthcare provider regarding the necessity of an opioid analgesic for pain relief
• C. Recommend the client to discontinue the medication until contacting the healthcare provider
• D. Instruct the client on the use of acetaminophen every 4-6 hours as needed for headaches

Correct Answer: D

Rationale: The correct action for the nurse to take is to instruct the client to use acetaminophen for headaches. Acetaminophen is a suitable and safer option for managing headaches associated with calcium channel blockers like diltiazem. It is essential to avoid medications that can interact negatively with diltiazem, such as opioid analgesics, and to not discontinue the medication abruptly without consulting the healthcare provider. Monitoring for medication toxicity through blood samples is not typically indicated for managing headaches in this scenario.

3. After receiving the third dose of a new oral anticoagulant prescription, which action should the nurse implement? Select all that apply.

• A. Notify the healthcare provider of the finding
• B. Provide a PRN NSAID for gum discomfort
• C. Review the most recent coagulation lab values
• D. Complete a medication variance report

Correct Answer: C

Rationale: Reviewing the most recent coagulation lab values is crucial after receiving multiple doses of a new oral anticoagulant to ensure the patient is within the desired therapeutic range and to prevent adverse events related to over or under-anticoagulation. Notifying the healthcare provider of any concerning findings is important, but it may not be the immediate priority after receiving the third dose. Providing a PRN NSAID for gum discomfort is not typically indicated with oral anticoagulant therapy, as it may increase the risk of bleeding. Completing a medication variance report is more relevant in cases of medication errors or discrepancies, which may not apply in this scenario.

4. A client who is newly diagnosed with erosive esophagitis secondary to GERD experiences symptoms after taking lansoprazole PO for one full week. Which actions should the nurse take?

• A. Confirm that the client is taking the medication correctly
• B. Auscultate the client's bowel sounds and assess the apical pulse
• C. Advise the client that healing typically takes several weeks
• D. Notify the healthcare provider to consider a higher dose

Correct Answer: C

Rationale: It is essential for the nurse to educate the client that healing from erosive esophagitis typically takes several weeks to manage expectations. This information helps the client understand the timeline for improvement and reduces anxiety about the effectiveness of the treatment. It is not necessary to confirm the timing of medication intake, assess bowel sounds, or measure the apical pulse in this scenario. Since symptoms have persisted after one week of lansoprazole, it may not be appropriate to immediately escalate to a higher dose without further assessment or guidance from the healthcare provider.

5. A client who is recovering from an appendectomy is receiving narcotics. Earlier, the nurse witnessed the client's family pushing the pain pump. What should the nurse implement?

• A. Check client's level of consciousness
• B. Instruct the family not to push the button
• C. Stop the client's basal infusion
• D. Administer a narcotic reversal medication

Correct Answer: B

Rationale: Instructing the family not to push the button is necessary to prevent the client from receiving an excessive amount of narcotics, ensuring the safe and appropriate use of the pain pump. Educating the family on the proper use of the pump helps maintain the client's pain management within prescribed limits and prevents accidental overdosing.