a client with a history of coronary artery disease is experiencing chest pain what is the priority action for the lpnlvn to take a client with a history of coronary artery disease is experiencing chest pain what is the priority action for the lpnlvn to take
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Nursing Elites

HESI LPN

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1. A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.

2. A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?

Correct answer: D

Rationale: The priority nursing intervention for a child with leukemia admitted to the hospital with a fever is to monitor for signs of infection. Children with leukemia are immunocompromised, making them more susceptible to infections. Monitoring for signs of infection helps in early detection and timely intervention, which is crucial in preventing complications. Administering antibiotics (choice A) may be necessary if an infection is suspected or confirmed, but the priority is to assess for signs of infection first. Administering antipyretics (choice B) may help reduce fever, but it does not address the underlying cause, which could be an infection. Providing nutritional support (choice C) is important for overall health but is not the priority when a child with leukemia presents with a fever, as infection needs to be ruled out or managed first.

3. During a home visit for a family with a new baby, what should the nurse assess first?

Correct answer: A

Rationale: Assessing feeding patterns is the priority during a home visit for a family with a new baby because it is crucial for the health and growth of the newborn. By evaluating the feeding patterns, the nurse can ensure that the baby is receiving adequate nutrition and address any feeding issues promptly. While sleeping arrangements, support system, and immunization status are important aspects to assess during a home visit, they are not as critical as ensuring the newborn's nutritional needs are being met.

4. How should a healthcare provider respond to a parent concerned about their child's sleep pattern?

Correct answer: C

Rationale: When a parent expresses concerns about their child's sleep pattern, providing education on sleep hygiene is a beneficial response. Teaching parents about establishing a consistent sleep routine, creating a conducive sleep environment, and promoting healthy sleep habits can help address the child's sleep issues. This empowers the parent to make positive changes that can improve the child's sleep patterns. Recommending a sleep study (Choice A) may be premature and unnecessary without first addressing basic sleep hygiene. Suggesting increasing daytime naps (Choice B) may not always be appropriate and could further disrupt the child's nighttime sleep. Advising on medication use (Choice D) should be considered only after other non-pharmacological approaches have been tried and if deemed necessary by a healthcare provider.

5. A nurse is discussing the care of an infant with colic with the parents. What should the nurse explain is the cause of colicky behavior?

Correct answer: B

Rationale: The correct answer is B: Paroxysmal abdominal pain. Colic in infants is characterized by paroxysmal abdominal pain, leading to excessive crying and fussiness. It is not caused by inadequate peristalsis (Choice A), an allergic response to certain proteins in milk (Choice C), or a protective mechanism designed to eliminate foreign proteins (Choice D). Understanding that colic is primarily associated with abdominal pain helps healthcare providers provide appropriate care and support to parents dealing with colicky infants.

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