a 50 year old female is in the hospital with peripheral artery disease in the nursing care plan the nurse lists the following nursing diagnosis ineffe
Logo

Nursing Elites

HESI LPN

PN Exit Exam 2023 Quizlet

1. A 50-year-old female is in the hospital with peripheral artery disease. In the nursing care plan, the nurse lists the following nursing diagnosis: Ineffective tissue perfusion: peripheral related to venous stasis. Which of the following would not be an appropriate nursing action to list in the implementation of this diagnosis?

Correct answer: A

Rationale: Keeping the client’s extremities cold would worsen perfusion issues and is not recommended. In peripheral artery disease, maintaining warmth is crucial to promote vasodilation and improve blood flow. Checking peripheral pulses for strength and symmetry, keeping the client's legs elevated to reduce venous stasis, and monitoring for constrictions that may impair circulation are appropriate nursing actions to enhance tissue perfusion in this case. Thus, option A is incorrect as it would hinder perfusion in the affected extremities.

2. When documenting information in a client's medical record, what should the nurse do?

Correct answer: D

Rationale: When documenting information in a client's medical record, the nurse should end each entry with their signature and title. This practice is crucial for legal and professional standards compliance as it ensures that the documentation is attributable to the responsible individual. Choices A, B, and C are incorrect because while crossing out errors, using a black ink pen, and leaving a blank line before each entry are good practices, they are not as critical as ensuring each entry is signed and titled by the nurse for accountability and traceability.

3. 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.

4. What is the function of the enzyme lactase in the digestive system?

Correct answer: A

Rationale: The correct answer is A: 'Breaks down lactose into glucose and galactose.' Lactase is an enzyme in the small intestine that specifically breaks down lactose, the sugar found in milk, into glucose and galactose for absorption. Choice B is incorrect because proteins are broken down into amino acids by protease enzymes. Choice C is incorrect because the enzyme amylase converts starch into maltose. Choice D is incorrect as lipase enzymes break down fats into fatty acids.

5. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?

Correct answer: C

Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.

Similar Questions

The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?
The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?
The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement?
Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?
Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the PN to review?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses