a post operative client is recovering from a total knee replacement and is prescribed patient controlled analgesia pca what is the primary advantage o
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HESI LPN

HESI PN Exit Exam 2023

1. A post-operative client is recovering from a total knee replacement and is prescribed patient-controlled analgesia (PCA). What is the primary advantage of PCA for managing post-operative pain?

Correct answer: A

Rationale: The primary advantage of PCA for managing post-operative pain is that it allows the client to control the administration of pain medication, leading to consistent pain control without overmedication. Choice B is incorrect as PCA does not eliminate the need for oral pain medication; it supplements it. Choice C is incorrect because while PCA can help reduce opioid consumption, it does not directly reduce the risk of opioid addiction. Choice D is incorrect as PCA actually requires close monitoring by nursing staff to ensure proper use and prevent complications.

2. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?

Correct answer: D

Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.

3. The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops are used to anesthetize the eye if eye pain is experienced. What action should the PN implement?

Correct answer: C

Rationale: Pilocarpine eye drops are used to reduce intraocular pressure in glaucoma, not to anesthetize the eye. The PN should reteach the client about the purpose of the medication to ensure proper use and understanding, which is crucial for effective treatment. Choice A is incorrect because just documenting understanding without addressing the client's misconception is not enough. Choice B is incorrect as it provides incorrect information about the purpose of the eye drops and may lead to further misunderstanding. Choice D is incorrect as it provides inaccurate information stating that the drops provide pain relief, which is not their primary purpose.

4. What is an essential nursing action before administering a blood transfusion?

Correct answer: B

Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.

5. Which nursing intervention is most appropriate for managing delirium in an elderly patient?

Correct answer: C

Rationale: Encouraging family presence is the most appropriate intervention for managing delirium in elderly patients. This intervention provides orientation, reassurance, and comfort, which can help reduce confusion and anxiety, thus aiding in managing delirium. Keeping the room brightly lit (Choice A) may worsen delirium as it can disrupt the patient's sleep-wake cycle. Administering sedatives (Choice B) should be avoided unless absolutely necessary due to the risk of worsening delirium. Restricting fluids (Choice D) is not a recommended intervention for managing delirium, as hydration is important for overall patient well-being.

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