HESI EXIT V2 2023
The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client
... [Show More] to best tolerate the ambulation?
- Premedicate the client with an analgesic before ambulating.
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?
- Check the client status and lead placement.
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)
The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?
- Status of airway
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?
- Limiting movement and abduction of the right arm
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?
- Pulmonary embolism
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?
- Smoking history
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?
- "Moving to a warmer climate should help."
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? - Crackles
The LPN/LVN is collecting data on a client with a diagnosis of right-
sided heart failure. The nurse should expect to note which specific characteristic of this condition?
- Dependent edema
The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which?
- Normal, caused by increased blood flow through the leg
A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may stimulate which?
- Vagus nerve to slow the heart rate
A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection?
- Staphylococcal infection
client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings?
- The boot has been applied too tightly
A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain?
- Variant angina
The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA?
- Hyperactive bowel sounds in the area
An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response?
- Denial
A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure?
- Prior reaction to contrast media
A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? - Caffeine
An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a non-cardiac problem? - "Does the pain get worse when you breathe in?"
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? - Bathroom privileges and self-care activities
The LPN/LVN is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use?
- Surgical tourniquet
A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?
- Bed rest, with elevation of the affected extremity
A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client?
- With the foot of the bed elevated
The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? - Bilberry
The LPN/LVN is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply.
2. Be careful not to injure the legs or feet.
4. Walk each day to increase circulation to the legs.
5. Cut down on the amount of fats consumed in the diet.
A client is at risk for developing disseminated intravascular coagulopathy (DIC). The LPN/LVN should become concerned with which fibrinogen level?
- 90 mg/dL
A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The LPN/LVN should take which action first?
- Assist the client to sit or lie down.
The LPN/LVN notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? - Reviews the intake and output records for the last 2 days
A client brings the following medications to the clinic for a yearly physical. The LPN/LVN realizes which medication has been prescribed to treat heart failure? - Digoxin (Lanoxin)
1. A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? - Restricting the client's potassium intake
A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? - Antihypertensives
The LPN/LVN finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"? - "Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" [Show Less]