a client post coronary artery bypass graft cabg surgery is concerned about the risk of infection what is the most important preventive measure the nur
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. A client post-coronary artery bypass graft (CABG) surgery is concerned about the risk of infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?

Correct answer: D

Rationale: The correct answer is D: 'Keep the incision sites clean and dry.' After CABG surgery, maintaining the cleanliness and dryness of the incision sites is crucial to prevent infections. This practice reduces the risk of introducing harmful microorganisms to the surgical wound, promoting healing and preventing complications. Option A, while important, does not fully encompass the preventive measures necessary to avoid infections post-surgery. Option B is significant if antibiotics are prescribed, but ensuring cleanliness directly addresses infection prevention. Option C is reactive and focuses on addressing infection after it occurs, rather than proactively preventing it.

2. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?

Correct answer: A

Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.

3. When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?

Correct answer: C

Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (Choice A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (Choice B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (Choice D) is also important but comes after ensuring safe transportation and evacuation plans are in place.

4. Which electrolyte imbalance is most commonly associated with seizures?

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

5. Based on the computer documentation in the EMR, which action should the PN implement?

Correct answer: A

Rationale: The rubella vaccine is crucial for preventing rubella infection, which can cause severe congenital disabilities if contracted during pregnancy. Administering the vaccine subcutaneously is the correct action based on EMR documentation. Observing breastfeeding, calling the nursery for blood type results, and administering pain medication are not indicated by the EMR documentation and are not relevant to the situation described in the question.

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