HESI LPN
PN Exit Exam 2023 Quizlet
1. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?
- A. Apply an ice pack to the incision site.
- B. Monitor the client's temperature.
- C. Document the findings and continue to monitor.
- D. Notify the healthcare provider.
Correct answer: D
Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.
2. The nurse is caring for a client with pericarditis. Which of the following nursing interventions will promote comfort for the client?
- A. Auscultating the client's heart sounds
- B. Provide the client with a diversionary activity
- C. Encourage deep breathing
- D. Maintain a patent intravenous access
Correct answer: B
Rationale: Providing a diversionary activity is the most appropriate nursing intervention to promote comfort for a client with pericarditis. This intervention helps to distract the patient and reduce discomfort by focusing their attention elsewhere. Auscultating heart sounds, while important for monitoring the condition, does not directly address the client's comfort. Encouraging deep breathing can be beneficial for some conditions but may not be specifically aimed at promoting comfort in pericarditis. Maintaining a patent intravenous access is essential for treatment access and management of the condition, but it does not directly promote comfort for the client.
3. The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?
- A. Explain how to use a communication board
- B. Document progress in the use of the communication board
- C. Encourage voiding by assisting the client to the bedside commode
- D. Establish a bladder training schedule and methods
Correct answer: C
Rationale: Assisting the client to the bedside commode is an appropriate task for the UAP as it involves basic patient care and mobility assistance, which are within the UAP's scope of practice. Options A and B involve communication techniques and documentation, which are more appropriate for licensed nursing staff. Option D involves establishing a bladder training schedule, which requires assessment and planning skills beyond the UAP's role.
4. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?
- A. The newborn is infected with an infectious blood-borne disease
- B. The newborn needs phototherapy for physiologic jaundice
- C. The mother's Rh antibodies are present in the neonatal blood
- D. The mother no longer needs Rho immune globulin injections
Correct answer: C
Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.
5. The PN assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the PN provide the UAP?
- A. Assist the client with a hot bath
- B. Encourage self-care but allow rest periods
- C. Face the client directly when speaking
- D. Keep the head of the bed elevated at all times
Correct answer: B
Rationale: During an acute exacerbation of multiple sclerosis, it is important to encourage self-care to maintain the client's independence. Allowing rest periods helps prevent fatigue, which is crucial in managing MS exacerbations. Choice A is incorrect as hot baths can exacerbate symptoms in MS. Choice C is about communication techniques and not directly related to client care during an exacerbation. Choice D is not a priority intervention during an MS exacerbation.
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