Arlyn Source Hesi Exit Practice Flashcards
The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible.
Which action should the PN implement?
A. Review the client’s expectations of elimination after surgery.
B. Verify that the client had nothing by mouth (NPO) for the past 24 hours.
C. Ask the client if he finished the bowel sterilization prescription.
D. Determine if this is the first indwelling catheter the client has had.
Choice A:
This is the best action for the PN to implement because it addresses the client’s question and provides an opportunity to educate the client about the fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will affect the client’s elimination and body image.
For the past six hours, a postoperative male client has refused pain medication because he believed that he could “tough it out.” When an opioid analgesic is administered, the client has difficulty obtaining a satisfactory level of comfort.
Which action is best for the practical nurse (PN) to use in assisting this client to deal with his pain?
A. Dim the lights in the room and close the door.
B. Guide the client through slow, rhythmic breathing.
C. Turn the television on to the client’s favorite show.
D. Obtain a prescription for a higher dose of pain medication.
Choice B:
This is the best action for the PN to use in assisting this client to deal with his pain because it provides a non- pharmacological method of pain relief that can enhance the effect of the opioid analgesic. Slow, rhythmic breathing can help the client relax, distract from the pain, and increase oxygenation and blood flow.
A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), “Wow! You have big breasts.”
Which response is best for the PN to provide?
A. The size of my breasts is of no concern to you.
B. That language is not allowed.
C. Do you really think so?
D. If you talk like that again, I will tell your parents.
Choice B:
This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent’s atention to another topic or activity and document the incident.
The practical nurse (PN) is reviewing a client’s recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?
A. Glaucoma
B. Macular edema.
C. Cataract
D. Diabetic retinopathy
Choice A:
Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood flow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.
A client who is at full-term gestation is in active labor and complains of a cramp in her leg.
Which intervention should the practical nurse (PN) implement?
A. Massage the calf and foot.
B. Extend the leg and flex the foot.
C. Check the pedal pulse in the affected leg.
D. Elevate the leg above the heart.
E. None
Choice B:
Extending the leg and flexing the foot helps to relieve the cramp by stretching the muscles involved. This is a safe and effective method to alleviate muscle cramps.
