at 1200 the practical nurse learns that a clients 0900 dose of an anticonvulsant was not given the next scheduled dose is at 2100 which action should
Logo

Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

Correct answer: B

Rationale: Administering the missed dose as soon as possible is crucial in this situation. Missing an anticonvulsant dose can lead to breakthrough seizures, which are harmful to the client. Administering the missed dose promptly helps maintain the therapeutic level of the medication and reduces the risk of seizure activity. Giving half the dose may not provide adequate protection against seizures. Delaying the dose until the next scheduled time increases the time the client is without the medication, potentially increasing the risk of seizures. Withholding the missed dose unless seizure activity occurs is not recommended, as prevention is key in managing anticonvulsant therapy.

2. A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?

Correct answer: A

Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.

3. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?

Correct answer: C

Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.

4. 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.

5. The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/hr. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding?

Correct answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.

Similar Questions

Inspiratory and expiratory stridor may be heard in a client who:
The PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?
What is the first action a healthcare professional should take when a patient’s nasogastric (NG) tube becomes clogged?
A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses