a client with a history of atrial fibrillation is receiving warfarin coumadin which laboratory value should the lpnlvn monitor closely while the clien

HESI LPN

Fundamentals HESI

1. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the LPN/LVN monitor closely while the client is taking this medication?

A. Blood glucose level
B. Prothrombin time (PT) and INR
C. Serum potassium level
D. Serum creatinine level

Correct answer: B

Rationale: The LPN/LVN should closely monitor Prothrombin time (PT) and INR (Choice B) levels in a client receiving warfarin. These values are crucial to ensure the medication's effectiveness and prevent complications like bleeding. Monitoring blood glucose level (Choice A) is not directly relevant to warfarin therapy. While serum potassium level (Choice C) and serum creatinine level (Choice D) are important for other conditions or medications, they are not specifically required to be monitored when a client is on warfarin.

2. During a Weber test, what is an appropriate action for the nurse to take?

A. Deliver a series of high-pitched sounds at random intervals.
B. Place an activated tuning fork in the middle of the client's forehead.
C. Hold an activated tuning fork against the client's mastoid process.
D. Whisper a series of words softly into one ear.

Correct answer: B

Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.

3. A healthcare professional is preparing to insert an NG tube for a client admitted with bowel obstruction. Which of the following should the healthcare professional do first?

A. Explain the procedure to the client
B. Measure the length of the NG tube
C. Lubricate the NG tube
D. Place the client in a high Fowler’s position

Correct answer: A

Rationale: Explaining the procedure to the client is the initial and most important step that the healthcare professional should take before inserting an NG tube. By explaining the procedure, the healthcare professional ensures the client's understanding, obtains informed consent, and fosters cooperation. Measuring the length of the NG tube, lubricating the tube, and positioning the client in a high Fowler's position are essential steps in the NG tube insertion process but should come after the client has been informed and consented to the procedure.

4. Which toy is most appropriate for an 18-month-old child?

A. A pull toy
B. A puzzle with large pieces
C. A book with large pictures
D. A doll with small clothes

Correct answer: A

Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.

5. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

A. Carry a client's soiled linens out of the room in a mesh linen bag
B. Place a client who has tuberculosis in a room with negative-pressure airflow
C. Provide disposable plates and utensils for a client who is HIV-positive
D. Dispose of a client's blood-saturated dressing in a biohazard bag

Correct answer: B

Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.