HESI PN Fundamental V2: Questions& Answers: Updated Solution

During the initial physical assessment of a newly admitted client with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? A. The nurse also should have instituted a plan to increase activity. B. The nurse provided supportive nursing care for the well-being of the client. C. Debridement of the pressure ulcer should have been done before the dressing was applied. D. Treatment should not have been instituted until the health care provider's prescriptions were received. (Ans- B. The nurse provided supportive nursing care for the well-being of the client. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take? A Ask the client if he is okay. B Call security from the room. C Find out if there is anyone else in the room. D Ask security to make sure the room is safe (Ans- D. Ask security to make sure the room is safe To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every A. 4 to 8 hours B. 12 to 24 hours C. 24 to 48 hours D. 72 to 96 hours (Ans- D. 72 to 96 hours A LPN/LVN is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A. Ask the client what is the client's acceptable level of pain. B. Eliminate all activities that precipitate the pain. C. Administer the pain medications regularly around the clock. D. Use a different pain scale each time to promote patient education. E. Assess the client's pain every 15 minutes (Ans- A. Ask the client what is the client's acceptable level of pain. C. Administer the pain medications regularly around the clock The LPN/LVN is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply A. Allergy to the medication B. Itching in the ear canal C. Drainage from the ear canal D. Tympanic membrane rupture E. Partial hearing loss in the affected ear (Ans- A. Allergy to the medication C. Drainage from the ear canal D. Tympanic membrane rupture What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply A. Tetany B. Seizures