2017 PN Hesi Exit V2
1) The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?
1. Provide the client with a walker.
2. Remove the telemetry equipment.
3. Encourage the client to c...
1) The LPN/LVN is preparing to ambulate a postoperative client after
cardiac surgery. The nurse plans to do which to enable the client to best
tolerate the ambulation?
1. Provide the client with a walker.
2. Remove the telemetry equipment.
3. Encourage the client to cough and deep breathe.
4. Premedicate the client with an analgesic before ambulating.
Correct Answer: 4. Premedicate the client with an analgesic before
ambulating.
2) A client is wearing a continuous cardiac monitor, which begins to
alarm at the nurse's station. The nurse sees no electrocardiographic
complexes on the screen. The nurse should do which first?
1. Call a code blue.
2. Call the health care provider.
3. Check the client status and lead placement.
4. Press the recorder button on the ECG console.
Correct Answer: 3. Check the client status and lead placement.
3) The LPN/LVN in a medical unit is caring for a client with heart
failure. The client suddenly develops extreme dyspnea, tachycardia, and
lung crackles, and the nurse suspects pulmonary edema. The nurse
immediately notifies the registered nurse and expects which
interventions to be prescribed? Select all that apply.
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide (Lasix)
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
,6. Placing the client in a low-Fowler's side-lying position
4) The nurse is monitoring a client following cardioversion. Which
observations should be of highest priority to the nurse?
1. Blood pressure
2. Status of airway
3. Oxygen flow rate
4. Level of consciousness
Correct Answer: 2. Status of airway
5) The nurse is assisting in caring for the client immediately after
insertion of a permanent demand pacemaker via the right subclavian
vein. The nurse prevents dislodgement of the pacing catheter by
implementing which intervention?
1. Limiting movement and abduction of the left arm
2. Limiting movement and abduction of the right arm
3. Assisting the client to get out of bed and ambulate with a walker
4. Having the physical therapist do active range of motion to the right
arm
Correct Answer: 2. Limiting movement and abduction of the right arm
6) A client diagnosed with thrombophlebitis 1 day ago suddenly
complains of chest pain and shortness of breath, and the client is visibly
anxious. The LPN/LVN understands that a life-threatening complication
of this condition is which?
7) A 24-year-old man seeks medical attention for complaints of
claudication in the arch of the foot. The nurse also notes superficial
thrombophlebitis of the lower leg. The nurse should check the client for
which next?
1. Smoking history
2. Recent exposure to allergens
3. History of recent insect bites
4. Familial tendency toward peripheral vascular disease
Correct Answer: 1. Smoking history
8) The nurse has reinforced instructions to the client with Raynaud's
disease about self-management of the disease process. The nurse
determines that the client needs further teaching if the client states
which?
1. "Smoking cessation is very important."
2. "Moving to a warmer climate should help."
3. "Sources of caffeine should be eliminated from the diet."
4. "Taking nifedipine (Procardia) as prescribed will decrease vessel
spasm."
Correct Answer: 2. "Moving to a warmer climate should help."
9) A client with myocardial infarction suddenly becomes tachycardic,
shows signs of air hunger, and begins coughing frothy, pink-tinged
sputum. The nurse listens to breath sounds, expecting to hear which
breath sounds bilaterally?
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