HESI LPN
HESI PN Exit Exam 2024 Quizlet Questions
Question 1 of 5
A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the PN implement?
Correct Answer: D
Rationale: During labor, muscle cramps are common due to prolonged muscle tension. The correct intervention to alleviate a cramp in the leg is to extend the leg and flex the foot. This action helps relieve the muscle spasm by stretching and contracting the muscles. Massaging the calf and foot (Choice A) may not be as effective in relieving the cramp as extending and flexing the leg. Elevating the leg above the heart (Choice B) is not necessary and may not directly address the cramp. Checking the pedal pulse (Choice C) is important for assessing circulation, but it does not directly address the muscle cramp.
Question 2 of 5
A client who had a thyroidectomy 24 hours ago reports tingling around the mouth and in the fingertips. What should the nurse do first?
Correct Answer: A
Rationale: Tingling around the mouth and in the fingertips can indicate hypocalcemia, a potential complication after thyroidectomy due to accidental damage to the parathyroid glands. Checking calcium levels is crucial as it helps in diagnosing hypocalcemia accurately. Administering calcium without knowing the actual calcium levels can be dangerous. Assessing the incision site for bleeding is important but not the priority in this situation. Notifying the healthcare provider can be done after assessing and managing the immediate concern of hypocalcemia.
Question 3 of 5
A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client's care plan to manage this type of pain?
Correct Answer: B
Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.
Question 4 of 5
A client is recovering from a craniotomy and has a ventriculostomy in place. The nurse notices the drainage from the ventriculostomy is suddenly increasing. What should the nurse do first?
Correct Answer: C
Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.
Question 5 of 5
A client with a recent total knee replacement is scheduled for physical therapy. The client refuses to participate, stating that the pain is too intense. What should the nurse do first?
Correct Answer: A
Rationale: Administering pain medication before physical therapy helps manage the pain, making it easier for the client to participate in the necessary exercises to improve recovery and prevent complications such as joint stiffness. Choice B is not the first step as addressing the pain should take precedence. Choice C is important but should come after managing the pain to facilitate participation. Choice D involves another healthcare provider and is not the immediate action needed in this situation.