a client with pneumonia has a decrease in oxygen saturation from 94 to 88 while ambulating based on these findings which intervention should the lpnlv
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?

Correct answer: A

Rationale: The correct intervention is to assist the client back to bed. A decrease in oxygen saturation while ambulating indicates hypoxemia, and the immediate priority is to stabilize oxygen levels. Returning the client to bed allows for rest and decreased oxygen demand, potentially preventing further desaturation. Encouraging continued ambulation (Choice B) may worsen the hypoxemia by increasing oxygen demand. Obtaining portable oxygen (Choice C) is essential but should not delay addressing the low oxygen saturation. Moving the oximetry probe (Choice D) may not address the underlying cause of decreased oxygen saturation and should not be the first intervention.

2. A client with a history of atrial fibrillation is taking digoxin (Lanoxin). Which finding should the healthcare provider be notified of immediately?

Correct answer: A

Rationale: A heart rate of 52 beats per minute is a critical finding in a client taking digoxin, as it may indicate digoxin toxicity. Digoxin can cause bradycardia as a side effect, and a heart rate of 52 bpm warrants immediate attention to prevent adverse outcomes. Monitoring and reporting changes in heart rate are crucial in clients on digoxin therapy to prevent serious complications. The other vital signs and laboratory values provided are within normal ranges or not directly associated with digoxin toxicity in this scenario, making them lower priority for immediate reporting.

3. The nurse manager hears a healthcare provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the healthcare provider's complaints. The nurse manager's next action should be to

Correct answer: D

Rationale: The correct action for the nurse manager in this situation is to request an immediate private meeting with the healthcare provider and staff nurse. By doing so, the nurse manager can facilitate a more appropriate and professional discussion of the issues at hand in a private setting. Option A, which involves addressing the behavior quietly, may not effectively resolve the issue as it needs to be openly discussed. Option B is not advisable as the nurse manager should intervene to address the situation and provide support. Option C, notifying other administrative personnel, may escalate the situation unnecessarily before attempting to resolve it directly with the involved parties.

4. During the physical assessment of a client, which technique should a nurse use when performing a Romberg's test?

Correct answer: C

Rationale: During a Romberg's test, the nurse assesses the client's balance. Having the client stand with arms at her sides and feet together is the correct technique. This position helps the nurse observe for swaying or loss of balance, indicating alterations in balance. Choices A and B are incorrect as they are not part of Romberg's test and do not assess balance. Choice D is also incorrect as direct percussion over the kidneys is not associated with a Romberg's test.

5. The healthcare provider retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the healthcare provider administer to the client?

Correct answer: C

Rationale: The correct dosage calculation is to divide the prescribed dose by the concentration of the medication to determine the volume needed. In this case, 3 mg (prescribed dose) divided by 4 mg/mL (concentration) equals 0.75 mL. Therefore, the healthcare provider should administer 0.75 mL of hydromorphone to the client. Choices A, B, and D are incorrect because they do not accurately calculate the required volume based on the prescription and concentration provided.

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