HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. Which laboratory value is most important to monitor for a patient receiving heparin therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. International normalized ratio (INR)
Correct answer: C
Rationale: The correct answer is C, Partial thromboplastin time (PTT). PTT is monitored to assess the therapeutic effect of heparin therapy. It helps ensure that the heparin levels are within the desired range to prevent either clotting or excessive bleeding. Platelet count (A) is important but does not directly assess heparin's therapeutic effect. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor patients on warfarin, not heparin therapy.
2. While caring for a client with bilateral chest tubes, the bubbling in the water-seal chamber of the right chest tube stops. What action is most important for the nurse to take?
- A. Check the chest tube connections to the water-seal container
- B. Replace the water-seal collection container
- C. Increase the amount of wall suction connected to the right chest tube
- D. Milk the tubing connected to the right chest tube
Correct answer: A
Rationale: The most important action for the nurse to take when the bubbling in the water-seal chamber of the right chest tube stops is to check the chest tube connections to the water-seal container. This is crucial to ensure there are no disconnections or leaks affecting the bubbling. Replacing the water-seal collection container (choice B) is not necessary unless there is a malfunction; increasing suction (choice C) without assessing the connections can be harmful, and 'milking' the tubing (choice D) is an inappropriate action that can cause damage to the system.
3. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care?
- A. Confusion
- B. Check neuro vital signs every 4 hours.
- C. Maintain intravenous access.
- D. Keep the suture line clean and dry.
Correct answer: C
Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
4. A client with a history of asthma is experiencing shortness of breath. What is the most appropriate action for the LPN/LVN to take first?
- A. Administer a bronchodilator as prescribed.
- B. Encourage the client to practice deep breathing exercises.
- C. Position the client in high Fowler's position.
- D. Obtain a peak flow reading.
Correct answer: A
Rationale: Administering a bronchodilator as prescribed is the most appropriate initial action for managing asthma-related shortness of breath. Bronchodilators help to open up the airways quickly, providing relief for the client. Encouraging deep breathing exercises may be beneficial in some situations but should not be the first action for acute shortness of breath in asthma. Positioning the client in high Fowler's position can also help improve breathing, but administering the bronchodilator takes precedence. Obtaining a peak flow reading is important in asthma management, but it is not the initial action needed to address acute shortness of breath.
5. Seizures in children most often result from
- A. an abrupt rise in body temperature
- B. an inflammatory process in the brain
- C. a temperature greater than 102°F
- D. a life-threatening infection
Correct answer: A
Rationale: Seizures in children most often result from an abrupt rise in body temperature, leading to febrile seizures. Febrile seizures are common in young children and are typically triggered by a rapid increase in body temperature, often due to infections or other causes. An inflammatory process in the brain (Choice B) is less common as a cause of seizures in children and is usually associated with specific conditions like encephalitis or meningitis. While a temperature greater than 102°F (Choice C) may trigger a febrile seizure, it is the abrupt rise in temperature that is the primary cause. Choice D, a life-threatening infection, is a broad and less specific cause compared to the direct trigger of an abrupt rise in body temperature.