the nurse enters a male clients room to administer routine morning medications and the client is on the phone which action is best for the nurse to ta
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Nursing Elites

HESI LPN

PN Exit Exam 2023 Quizlet

1. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?

Correct answer: B

Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.

2. 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.

3. The client diagnosed with HIV is taught by the nurse that the condition is transmitted through

Correct answer: A

Rationale: HIV can be transmitted from a mother to her baby during childbirth or breastfeeding, making choice A the correct answer. Tears, human bites, and insect bites are not common modes of HIV transmission. While human bites can potentially transmit the virus, it is less common compared to mother-to-child transmission.

4. A client is complaining of a tingling sensation in the fingers, nose tip, and earlobes 24 hours after a total thyroidectomy. Which measure should the PN implement first?

Correct answer: C

Rationale: The correct answer is C: Obtain prescribed calcium gluconate for tetany. Tingling sensations post-thyroidectomy may indicate hypocalcemia, a potential complication that requires prompt treatment with calcium gluconate to prevent tetany. Initiating L-thyroxine replacement therapy (choice B) is important but not the first priority in this situation. Applying sequential compression devices (choice A) is not indicated for tingling sensations and does not address the potential complication of hypocalcemia. Preparing for an emergency tracheotomy (choice D) is not warranted based on the client's symptoms of tingling sensations.

5. When teaching a patient with diabetes about foot care, which of the following should the nurse emphasize?

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across and filing the edges is crucial in diabetic foot care to prevent ingrown toenails and foot injuries. Soaking feet daily can lead to dryness and skin breakdown, increasing the risk of infection. Selecting well-fitting shoes is important to prevent pressure points and skin damage, not tight-fitting shoes. Using heating pads can result in burns or injuries due to decreased sensation in diabetic feet, so it's essential to avoid them.

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