a client is recovering from a craniotomy and has a ventriculostomy in place the nurse notices the drainage from the ventriculostomy is suddenly increa
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HESI PN Exit Exam 2024 Quizlet

1. 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.

2. A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?

Correct answer: A

Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.

3. The HCP gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her that she needs to increase foods in her diet because her hemoglobin is 8.2 grams/dL. When a list of iron-rich foods is given to the client, she tells the PN that she is a vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide?

Correct answer: A

Rationale: Vegetarians can increase their iron intake through plant-based sources such as green leafy vegetables, oatmeal, and legumes, which are rich in iron.

4. Which condition is commonly screened for in newborns using the Guthrie test?

Correct answer: A

Rationale: The Guthrie test is specifically designed to screen newborns for phenylketonuria (PKU), a metabolic disorder that can lead to intellectual disability if left untreated. Phenylketonuria is caused by the deficiency of an enzyme required to metabolize the amino acid phenylalanine. Screening for PKU in newborns is crucial as early diagnosis and intervention can prevent the severe consequences associated with the condition. Choices B, C, and D are incorrect as the Guthrie test is not used to screen for cystic fibrosis, Down syndrome, or sickle cell anemia.

5. The PN identifies an electrolyte imbalance, exhibited by changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first?

Correct answer: B

Rationale: Evaluating for muscle cramping, which is a sign of electrolyte imbalance, is crucial in this scenario. Electrolyte imbalances, especially involving potassium or calcium, can lead to serious complications such as arrhythmias or seizures, which need immediate attention. Recording eating patterns (choice A) may be important for overall assessment but is not the priority in this situation. Documenting abdominal girth (choice C) and elevating legs on pillows (choice D) are not directly related to addressing the immediate concern of electrolyte imbalance and its potential complications.

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