a female native american client who is receiving chemotherapy places a native artifact an indian medicine wheel in her hospital room the hcp removes t
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. A female Native American client who is receiving chemotherapy places a native artifact, an Indian medicine wheel, in her hospital room. The HCP removes the medicine wheel and tells the client, 'This type of thing does not belong in the hospital.' Which intervention should the PN implement?

Correct answer: B

Rationale: Acting as the client's advocate is the most appropriate intervention in this situation. Removing a culturally significant artifact without considering the client's beliefs and emotional needs can be distressing. By advocating for the client, the PN can ensure that the client's cultural practices are respected, which is crucial for her emotional and spiritual well-being during treatment. Choice A is incorrect because while chemotherapy adherence is important, it is not the most immediate concern in this scenario. The client's cultural needs and well-being take precedence. Choice C is incorrect because consulting with a Native American healer might not be necessary at this point and could delay addressing the immediate issue of advocating for the client's rights. Choice D is incorrect because simply reporting the client's feelings of culture shock to the HCP does not actively address the situation or advocate for the client's rights and cultural needs.

2. A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement?

Correct answer: A

Rationale: The correct action for the PN to implement is to teach the client to use a straw when taking the medication to reduce further tooth staining. Using a straw minimizes contact between the iron preparation and the teeth, helping prevent additional staining. Choice B is incorrect because withholding doses without consulting the healthcare provider could be detrimental to the client's health. Choice C is incorrect because darkening of tooth color is not an expected effect of liquid iron preparation and should not be reassured as a desired effect. Choice D is incorrect as it does not directly address the client's concern about tooth staining.

3. The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?

Correct answer: D

Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern. Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety. Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP. Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.

4. The nurse is performing a psychosocial assessment on an adolescent aged 14. Which emotional response is typical during early adolescence?

Correct answer: C

Rationale: Moodiness is a typical emotional response during early adolescence. Hormonal changes and developmental challenges contribute to this behavior. While anger and combativeness can also be present during adolescence, they are not as consistently typical as moodiness. Cooperativeness, on the other hand, is a trait more commonly associated with later stages of development and maturity, rather than early adolescence.

5. A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse’s best action?

Correct answer: C

Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.

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