based on the computer documentation in the emr which action should the pn implement

HESI LPN

PN Exit Exam 2023 Quizlet

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

A. Give the rubella vaccine subcutaneously
B. Observe the mother breastfeeding her infant
C. Call the nursery for the infant's blood type results
D. Administer hydrocodone/acetaminophen one tablet for pain

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.

2. While caring for a client with an AV fistula in the left forearm, the PN observed a palpable buzzing sensation over the fistula. What action should the PN take?

A. Loosen the fistula dressing
B. Report the presence of a bounding pulse
C. Document that the fistula is intact
D. Apply gentle pressure over the site

Correct answer: C

Rationale: A palpable buzzing sensation, known as a thrill, over an AV fistula indicates proper functioning. The correct action for the PN is to document that the fistula is intact. Choice A is incorrect because there is no need to loosen the fistula dressing when the thrill is felt. Choice B is incorrect as a bounding pulse is not related to the observed buzzing sensation. Choice D is incorrect because applying pressure is unnecessary when a thrill is present, indicating proper AV fistula function.

3. There has been a serious explosion at a local factory, and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?

A. A 30-year-old male who is able to walk into the hospital on his own but has numerous lacerations on the chest and face
B. A 45-year-old male who was brought in on a stretcher, has been assessed as having respiration and circulation within normal limits, and can follow simple commands
C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute

Correct answer: D

Rationale: The correct answer is D. The 19-year-old man with a respiration rate exceeding 30 breaths per minute is showing signs of respiratory distress, indicating a potentially life-threatening condition that requires immediate attention. Patients with respiratory distress should be prioritized as it is a critical condition. Choices A, B, and C describe patients with injuries that are less immediately life-threatening or who are more stable based on the provided information, so they can be attended to after the patient with respiratory distress. Therefore, the nurse should attend to the 19-year-old man first to address his respiratory distress and ensure his condition does not deteriorate further.

4. Which condition is commonly screened for in newborns using the Guthrie test?

A. Phenylketonuria (PKU)
B. Cystic fibrosis
C. Down syndrome
D. Sickle cell anemia

Correct answer: A

Rationale: The Guthrie test is specifically designed to screen newborns for phenylketonuria (PKU), a metabolic disorder that can lead to intellectual disability if left untreated. Phenylketonuria is caused by the deficiency of an enzyme required to metabolize the amino acid phenylalanine. Screening for PKU in newborns is crucial as early diagnosis and intervention can prevent the severe consequences associated with the condition. Choices B, C, and D are incorrect as the Guthrie test is not used to screen for cystic fibrosis, Down syndrome, or sickle cell anemia.

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

A. Hyponatremia
B. Hypercalcemia
C. Hyperkalemia
D. Hypokalemia

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.