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PN HESI Exit V2 EXAM 2022 160 VERIFIED Q & A.pdf, Exams of Nursing

PN HESI Exit V2 EXAM 2022 160 VERIFIED Q & A.pdf

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PN HESI Exit V2 EXAM 2022; 160 VERIFIED Q & A
04
pg. 1
HESI Exit V2 (Nurse Hero Review)
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.
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?
a.
Call a code blue.
b.
Call the health care provider.
c.
Check the client status and lead placement.
d.
Press the recorder button on the ECG console.
3.
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.
a. Administering oxygen
b.
c.
Administering furosemide (Lasix)
d.
Administering morphine sulfate intravenously
e.
Transporting the client to the coronary care unit
f.
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?
a.
Blood
pressure
b.
Status of airway
c.
Oxygen flow rate
d.
Level of consciousness
5.
The nurse is assisting in caring for the client immediately
after insertion of a permanent demand pacemaker via the right
Inserting a Foley catheter
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04

HESI Exit V2 (Nurse Hero Review)

  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.
  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? a. Call a code blue. b. Call the health care provider. c. Check the client status and lead placement. d. Press the recorder button on the ECG console.
    1. 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. a. Administering oxygen b. c. Administering furosemide (Lasix) d. Administering morphine sulfate intravenously e. Transporting the client to the coronary care unit f. Placing the client in a low-Fowler's side-lying position
  3. The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? a. Blood pressure b. Status of airway c. Oxygen flow rate d. Level of consciousness
  4. The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right Inserting a Foley catheter

04 subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? a. Limiting movement and abduction of the left arm b. Limiting movement and abduction of the right arm c. 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

  1. 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? a. Pneumonia b. Pulmonary edema c. Pulmonary embolism d. Myocardial infarction
  2. 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? a. Smoking history b. Recent exposure to allergens c. History of recent insect bites d. Familial tendency toward peripheral vascular disease
  3. 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? a. "Smoking cessation is very important." b. "Moving to a warmer climate should help." c. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."
  4. 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? a. Rhonchi b. Crackles c. Wheezes

04 and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? a. The boot has not yet dried. b. The boot is controlling leg edema. c. The boot is impairing venous return. d. The boot has been applied too tightly.

  1. 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 thatthe pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain? a. Stable angina b. Variant angina c. Unstable angina d. Nonanginal pain
  2. The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated tothe AAA? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in the area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen
  3. 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? a. Angry b. Denial c. Phobic d. Obsessive-compulsive
  4. A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item beforethe procedure? a. Intake and output b. Height and weight c. Peripheral pulse rates d. Prior reaction to contrast media

04

  1. A client is scheduled for a dipyridamole thallium scan. TheLPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? a. Caffeine b. Fatty meal c. Excess sugar d. Milk products
  2. 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? a. "Can you describe the pain to me?" b. "Have you ever had this pain before?" c. "Does the pain get worse when you breathe in?"
  3. A client with myocardial infarction (MI) has been transferredfrom 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? a. Strict bed rest for 24 hours b. Bathroom privileges and self-care activities c. Unrestricted activities because the client is monitored d. Unsupervised hallway ambulation with distances less than 200 feet
  4. 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? a. Surgical tourniquet b. Dry sterile dressings c. Incentive spirometer d. Over-the-bed trapeze
  5. A client is diagnosed with thrombophlebitis. The nurseshould tell the client that which prescription is indicated? a. Bed rest, with bathroom privileges only b. Bed rest, keeping the affected extremity flat c. Bed rest, with elevation of the affected extremity d. Bed rest, with the affected extremity in a dependent position

04 a. Reviews the intake and output records for the last 2 days b. Prescribes daily weights starting on the following morning c. Changes the time of diuretic administration from morning to evening d. Requests a sodium restriction of 1 g/day from the health care provider

  1. 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? a. Digoxin (Lanoxin) b. Warfarin (Coumadin) c. Amiodarone (Cordarone) d. Potassium chloride (K-Dur)
  2. A student nurse is assigned to assist in caring for a client withacute 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? a. Restricting the client's potassium intake b. Encouraging the client to rest after meals c. Administering the heparin with a 25 - gauge needle d. Holding the digoxin for a heart rate less than 60 beats per minute
  3. A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcingwhen teaching the client? a. Bed rest b. Restricting fluids c. Antihypertensives d. Maintaining a low-fiber diet
  4. The LPN/LVN finds a client tensing while lying in bed staring atthe 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!"? a. "Would you like a mild sedative to help you relax?" b. "Oh, don't worry, the weather is supposed to be sunny and clear today."

04 c. how the cardiac monitor works?" d. "I can appreciate your concerns. Your family can stay with you tonight if you want them to."

  1. The LPN/LVN is asked to assist another health care memberin providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? a. Shock b. Kidney dysfunction c. Respiratory insufficiency d. Increased intracranial pressure
  2. A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over thelast several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the LPN/LVN ask the client first? a. "Do you exercise regularly?" b. "Would you consider losing weight?" c. "Is there a history of diabetes mellitus in your family?" d. "When was the last time you had your blood pressure checked?"
  3. The client scheduled for a right femoropopliteal bypass graftis at risk for compromised tissue perfusion to the extremity. The LPN/LVN takes which action before surgery to address this risk? a. Having the client void before surgery b. Completing a preoperative checklist c. Marking the location of the pedal pulses on the right leg d. Checking the results of any baseline coagulation studies
  4. When preparing a client for a pericardiocentesis, which positiondoes the LPN/LVN place the client in? a. Supine with slight lowering of the head b. Lying on the right side with a pillow under the head c. Lying on the left side with a pillow under the chest wall d. angle
  5. For a client diagnosed with pulmonary edema, the LPN/LVN establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? Supine with the head of bed elevated at a 45 - to 60 - degree "Yes, this equipment is a little scary. Can we talk about

04 a. Oxygen assists in calming the client. b. Oxygen prevents the development of any thrombus formation. c. pectoris pain. d. Oxygen dilates the blood vessels, supplying more nutrients to the heart muscle.

  1. The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? a. Mental status b. Urinary output c. Respirations and blood pressure d. Temperature and blood pressure
  2. A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? a. "I am considering cutting my workload." b. "I need to cut down on cigarette smoking." c. "I am so relieved that my heart is repaired." d. "I need to adhere to my dietary restrictions."
  3. The LPN/LVN is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completingthe diet menu. Which beverage does the nurse instruct the clientto select from the menu? a. Tea b. Cola c. Coffee d. Lemonade
    1. The LPN/LVN is collecting data on a client with a diagnosisof angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediatelyasks the client which question? a. "Are you having any nausea?" b. "Where is the pain located?" c. "Are you allergic to any medications?" d. "Do you have your nitroglycerin with you?" Deficient oxygenation to heart cells results in angina

04

  1. The LPN/LVN has reinforced dietary instructions to a clientwith coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? a. "I need to substitute eggs and milk for meat." b. "I will eliminate all cholesterol and fat from my diet." c. diet." d. "I need to seriously consider becoming a strict vegetarian."
  2. The LPN/LVN is assisting in caring for a client in the telemetryunit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? a. Tall, peaked T waves b. ST segment depressions c. Shortened P-R intervals d. Shortening of the QRS complex
  3. The LPN/LVN is assisting in caring for a client in the telemetryunit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? a. Tall, peaked T waves b. ST-segment depression c. Prolonged P-R interval d. Widening of the QRS complex
  4. While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? a. "Your doctor expects me to prepare you for this procedure." b. "That's fine, if that's what you want. I'll call your health care provider." c. provider?" d. "I'm concerned with the way you've dismissed me. I know what I am doing." "So you're saying that you want to talk to your health care "I should routinely use polyunsaturated oils in my

04

  1. The LPN/LVN working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? a. The client is not experiencing nausea or vomiting. b. The pain is described as substernal and radiating to the left arm. c. tablets. d. The client says the pain began while trying to open a stuck dresser drawer.
  2. The LPN/LVN is discussing smoking cessation with aclient diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? a. "Since the damage has already been done, it will be all right to cut down a little at a time." b. "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." c. "If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." d. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."
  3. A client with heart failure is scheduled to be discharged tohome with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? a. Decrease in pedal edema b. High urine output during the day c. Weight gain of 2 to 3 pounds in a few days d. Cough accompanied by other signs of respiratory infection
  4. A client has experienced an episode of pulmonary edema. The LPN/ LVN determines that the client's respiratory status is improving if which breath sounds arenoted? a. Rhonchi b. Wheezes c. Crackles in the lung bases d. Crackles throughout the lung fields The pain has not been unrelieved by rest and nitroglycerin

04

  1. A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? a. Increased pulse rate b. Relief of apprehension c. Decreased urine output d. Increased blood pressure
  2. The LPN/LVN is providing discharge teaching for a post- myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? a. "I will take this medication every day." b. "I will take this medication every other day." c. "I will take this medication until I feel better." d. "I will take this medication only when I have pain."
  3. The LPN/LVN determines that a client with coronary artery disease (CAD) needs further teaching about disease management ifthe client makes which statement? a. "I will watch my weight gain." b. "I will avoid walking for exercise." c. "I will monitor my cholesterol intake." d. "I will follow a low-fat, low-salt diet."
  4. An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviewsthe plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? a. Monitor oxygen saturation levels. b. Place the client on a cardiac monitor. c. Measure blood pressure every 4 hours. d. Check capillary refill at least once per shift.
  5. The LPN/LVN is planning adaptations needed for activities ofdaily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client? a. Increase fluids to 3000 mL per day to promote renal perfusion. b. Consume 1 to 2 oz of liquor each night to promote vasodilation. c. Try to engage in vigorous activity to strengthen cardiac reserve. d. bowel movement. Take in adequate daily fiber to prevent straining during a

04 understands the instructions if the client states that which food item will be avoided? a. Catsup b. Sherbet c. Cooked cereal d. Leafy green vegetables

  1. A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. Theclient states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? a. Exposure to heat b. Being in a relaxed environment c. Prolonged episodes of inactivity d. Ingestion of coffee or chocolate
  2. A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign orsymptom that differentiates pericarditis from other cardiopulmonary problems? a. Anterior chest pain b. Pericardial friction rub c. Weakness and irritability d. Chest pain that worsens on inspiration
  3. The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted? a. Mild dyspnea after walking 10 feet b. Minimal chest pain rated 1 on a 1 - to- 10 pain scale c. Pulse rate that increases from 68 to 94 beats per minute d. Blood pressure that increases from 114/82 to 118/86 mm Hg
  4. The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the clientto select which meal? a. Sausage, pancakes, and toast b. Broccoli, buttered rice, and grilled chicken c. Hamburger, baked apples, and avocado salad d. Fresh strawberries, steamed vegetables, and baked fish

04

  1. A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action? a. Get a prescription for pain medication. b. Have the client stop and lie back down in bed. c. Report the complaint to the health care provider. d. Have the client continue to get out of bed and into a chair.
  2. The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with adiagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside? a. Bedside commode b. Rolling shower chair c. Oxygen tubing and flowmeter d. Twelve-lead electrocardiogram (ECG) machine
  3. The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? a. "I will walk for one-half hour daily." b. "As long as I exercise I can eat anything I wish." c. "My weight has nothing to do with this disease." d. "It doesn't matter if my father had high cholesterol."
  4. A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? a. I should take daily medication for life. b. I should eat a diet that is low in fat and cholesterol. c. I should continue to smoke to keep the metabolic rate high. d. I should begin to exercise if diet is not sufficient to achieve weight loss.
  5. The nurse is collecting data on a client who was just admittedto the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next? a. Ask whether the client wants to see a psychiatrist.

04 perform which intervention to care for this client in a holistic manner? a. Tell the client that this is not allowed. b. Tell the family member not to take the client outdoors. c. Give the client a cup of hot coffee before going outside. d. going outside.

  1. The LPN/LVN carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next? a. Do a repeat 12 - lead ECG. b. Wait to see whether the pain resolves. c. Report the episode of chest pain to the health care provider. d. provider's prescriptions.
  2. A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact? a. Most people love high-fat diets. b. Denial is a common occurrence early after MI. c. The client probably wants to belittle the opinion of the staff. d. The client is not motivated to learn about heart disease at this time.
  3. The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction(MI). Which are characteristics of a therapeutic environment? a. No stimulus, no stress b. Low stimulus, low stress c. High stimulus, low stress d. Moderate stimulus, low stress
  4. A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life.Which action by the nurse is therapeutic at this time? a. Tell the client that his fears are not rational. b. Tell the client that his life has not changed. c. Explore the specific concerns with the client. d. Tell the client to talk it out with the significant other. Give sublingual nitroglycerin (Nitrostat) per the health care Instruct the family member to dress the client warmly before

04

  1. A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check which? a. Blood pressure b. Cardiac rhythm c. Respiratory rate d. Peripheral pulses
  2. A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone throughthis for nothing." Which is an appropriate nursing response? a. "There is nothing to worry about." b. "You are concerned about losing your leg?" c. "There are many people with the same problem, and they are doing just fine." d. "You have the best health care provider in the city, and your health care provider will not let anything happen to you."
  3. The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. Thenurse should tell the client to do which? a. Bend the leg at the hip. b. Keep the ankles uncrossed. c. Place two pillows under the knees. d. Use the knee gatch on the bed controls.
  4. A client is admitted to the hospital with possible rheumatic heart disease. The LPN/LVN collects data from the client and checksthe client for which signs/symptoms? a. Skin scratches b. Vaginal itching c. Fever and sore throat d. Burning on urination
  5. A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure? a. Lung crackles, peripheral edema, and weight gain b. Confusion, decreasing level of consciousness, and aphasia c. Respiratory distress, chest pain, and the use of accessory muscles