during a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 30 meql which intervention should the pn recommen
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HESI LPN

HESI PN Exit Exam

1. During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding?

Correct answer: A

Rationale: The correct answer is to recommend increasing the intake of dried peaches and apricots. A serum potassium level of 3.0 mEq/L is considered low. Increasing the intake of potassium-rich foods can help raise the serum potassium level, preventing complications such as muscle weakness and cardiac arrhythmias. Choice B, reducing intake of red meats, is incorrect because red meats are not specifically related to potassium levels. Choice C, encouraging the use of a soft toothbrush, is unrelated to addressing low potassium levels. Choice D, forcing fluid intake to 1500 mL daily, is not the appropriate intervention for low serum potassium; instead, increasing potassium-rich foods is more beneficial.

2. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?

Correct answer: C

Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.

3. What is the correct order of steps in the nursing process?

Correct answer: A

Rationale: The correct order in the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment involves gathering information about the patient, Diagnosis is identifying the problem, Planning involves setting goals and outcomes, Implementation is carrying out the plan, and Evaluation is assessing the outcomes. Choices B, C, and D have the steps in the incorrect order, not following the standard nursing process framework. Therefore, the correct answer is option A.

4. Which type of isolation is required for a patient with measles?

Correct answer: B

Rationale: The correct answer is B: Airborne isolation. Measles is highly contagious and can be transmitted through airborne particles, so airborne isolation is necessary to prevent its spread. Choice A, Contact isolation, is incorrect because measles is not primarily transmitted through direct contact. Choice C, Droplet isolation, is also incorrect as measles is not transmitted through large droplets but through smaller airborne particles. Choice D, Reverse isolation, is used to protect a patient from outside infections, not to prevent the spread of a contagious disease like measles.

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

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.

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