an 8 year old is placed in 90 90 traction for a fractured femur that resulted from a motor vehicle collision which finding requires further action by
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HESI LPN

HESI PN Exit Exam 2024

1. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?

Correct answer: C

Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.

2. Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

Correct answer: B

Rationale: A heart rate of 120 beats per minute is within the normal range for a 2-month-old infant. Therefore, it is safe to administer the digoxin and document the heart rate as part of routine care. Choice A is incorrect as withholding the medication is not necessary since the heart rate is normal. Choice C is incorrect as there is no need to delay the administration until the next scheduled dose when the heart rate is within the normal range. Choice D is incorrect as the primary nurse is not needed to administer the medication since the heart rate is normal and falls within the safe range for administration.

3. While caring for a client with a new tracheostomy, the nurse notices that the client is attempting to speak but is unable to. What should the nurse explain to the client regarding their inability to speak?

Correct answer: B

Rationale: The correct answer is B. The tracheostomy tube bypasses the vocal cords, preventing air from reaching them, which is necessary for speech. This makes speaking difficult but not impossible. Removing the tracheostomy tube does not automatically restore the ability to speak (choice C). While a speaking valve can be added later to allow speech, initially, the tracheostomy tube itself hinders air from reaching the vocal cords, making speech difficult (choice D is incorrect). Choice A is incorrect as the tracheostomy tube does not block the vocal cords directly; instead, it prevents air from reaching them.

4. Which electrolyte imbalance is most commonly associated with seizures?

Correct answer: A

Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.

5. During a blood transfusion, which sign or symptom should prompt the healthcare provider to immediately stop the transfusion?

Correct answer: B

Rationale: The correct answer is B: Elevated temperature and chills. These symptoms are indicative of a transfusion reaction, which can be severe and life-threatening. It is crucial to stop the transfusion immediately and notify the healthcare provider for further assessment and management. Elevated temperature and chills are classic signs of a transfusion reaction, specifically indicating a possible febrile non-hemolytic reaction. Choice A, a slight increase in blood pressure, is not typically a reason to stop a transfusion unless it is a significant sudden increase. Mild nausea (Choice C) and a slight headache (Choice D) are common side effects of blood transfusions and are not primary indicators of a transfusion reaction that require immediate cessation of the transfusion.

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