at the end of a 12 hour shift the pn observes the urine in a clients drainage bag as seen in the picture which action should the pn take next
Logo

Nursing Elites

HESI LPN

HESI PN Exit Exam 2024 Quizlet

1. At the end of a 12-hour shift, the PN observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next?

Correct answer: D

Rationale: Noting the white blood cell count is the most appropriate action in this situation. Changes in urine appearance could indicate infection, and assessing the white blood cell count helps in evaluating the possibility of infection. This is crucial for understanding the client's overall condition. The other options are not directly related to assessing infection based on urine appearance. Offering analgesics, checking glucose levels, or determining bladder distention may not address the underlying issue of a potential infection.

2. What is a priority when providing care for a patient with a newly inserted tracheostomy?

Correct answer: C

Rationale: When caring for a patient with a newly inserted tracheostomy, the priority is to monitor for signs of infection and ensure a patent airway. This is crucial to prevent complications such as airway obstruction or infection. While keeping the tracheostomy tube clean and dry is important for overall care, it is not the highest priority when compared to ensuring a patent airway. Providing regular oral hygiene is essential for the patient's comfort but takes a secondary role to maintaining airway patency. Encouraging the patient to cough and deep breathe may be beneficial but is not as critical as monitoring for infection and keeping the airway clear.

3. What is the primary reason for applying sequential compression devices (SCDs) to a patient’s legs postoperatively?

Correct answer: A

Rationale: The correct answer is A: To prevent deep vein thrombosis (DVT). Sequential compression devices (SCDs) are used postoperatively to prevent DVT by promoting blood circulation in the legs. This helps reduce the risk of blood clots forming in the deep veins of the legs. Choice B, to promote wound healing, is incorrect as SCDs are primarily used for circulatory purposes rather than wound healing. Choice C, to reduce postoperative pain, is incorrect as the primary purpose of SCDs is not pain management but rather prevention of DVT. Choice D, to maintain body temperature, is incorrect as SCDs are not designed for regulating body temperature but for preventing circulatory issues.

4. Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?

Correct answer: C

Rationale: The correct answer is C: Serum Creatinine. Serum creatinine is a key indicator of kidney function. Reviewing this value is crucial as it helps assess the client's risk for nephrotoxicity before administering the antibiotic. Elevated serum creatinine levels can indicate impaired kidney function, which would increase the risk of nephrotoxicity. Choices A, B, and D are not as directly related to kidney function and nephrotoxicity. Hemoglobin and hematocrit levels assess for anemia, serum calcium levels monitor calcium balance, and WBC count evaluates for infections. While these values are important for overall patient assessment, they are not as specific to assessing nephrotoxicity risk as serum creatinine.

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.

Similar Questions

The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?
Which of the following dietary modifications should be recommended for a patient with chronic kidney disease (CKD)?
The nurse is caring for an elderly female client who tells the nurse, 'When I sneeze, I wet my pants.' After discussing the client's complaint with the charge nurse, the nurse plans to reinforce teaching about the importance of Kegel exercises. What muscles are involved in these exercises?
A Native American client is admitted with a diagnosis of psychosis not otherwise specified. The client's family seems to regard the client's hallucinations as normal. What assessment can be made?
The client diagnosed with HIV is taught by the nurse that the condition is transmitted through

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