HESI LPN
PN Exit Exam 2023 Quizlet
1. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?
- A. Withhold the medication and notify the charge nurse
- B. Give the medication and document the heart rate
- C. Withhold the medication until the next scheduled dose
- D. Request the charge nurse to administer the medication
Correct answer: B
Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.
2. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Assist the client back to the room
- C. Have the client sit down in the hall
- D. Obtain a 12-lead electrocardiogram
Correct answer: C
Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.
3. A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient’s care. Which of the following is NOT a task related to the nurse’s intraoperative care?
- A. Go over the surgical procedure with the patient before he or she is anesthetized
- B. Strictly adhere to asepsis during all intraoperative procedures
- C. Provide emotional support to the patient and their family
- D. Monitor the patient’s physical status
Correct answer: A
Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.
4. A post-operative client is prescribed sequential compression devices (SCDs) while on bed rest. What is the primary purpose of this device?
- A. To prevent deep vein thrombosis (DVT).
- B. To improve circulation in the legs.
- C. To prevent pressure ulcers.
- D. To alleviate post-operative pain.
Correct answer: A
Rationale: The correct answer is A: 'To prevent deep vein thrombosis (DVT).' Sequential compression devices (SCDs) are primarily used to prevent deep vein thrombosis (DVT) by promoting blood flow in the legs and reducing venous stasis, which is a common risk for post-operative clients who are on bed rest. While SCDs do improve circulation in the legs indirectly, their primary purpose is DVT prevention. Preventing pressure ulcers is typically achieved through repositioning and support surfaces, not with SCDs, making choice C incorrect. SCDs are not used to alleviate post-operative pain, so choice D is also incorrect.
5. A client who is post-operative from a carotid endarterectomy is experiencing difficulty swallowing. What is the nurse's priority action?
- A. Administer a prescribed antiemetic.
- B. Assess the client’s airway and respiratory status.
- C. Elevate the head of the bed.
- D. Encourage the client to take small sips of water.
Correct answer: B
Rationale: The correct answer is to assess the client’s airway and respiratory status (Choice B). Difficulty swallowing after carotid endarterectomy could indicate swelling or nerve damage affecting swallowing, which may compromise the airway. Assessing the airway and respiratory status is crucial to ensure the client's ability to breathe. Administering an antiemetic (Choice A) is not the priority as the primary concern is airway patency. Elevating the head of the bed (Choice C) can help with swallowing difficulties but does not address the immediate risk to the airway. Encouraging the client to take small sips of water (Choice D) is contraindicated if there is a risk of compromised airway due to swallowing difficulties.
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