at a mobile screening clinic a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis to auscultate the aortic val
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, where should the nurse place the stethoscope?

Correct answer: A

Rationale: The correct location to auscultate the aortic valve is the second intercostal space to the right of the sternum. This area corresponds to the aortic valve area where aortic valve sounds are best heard. Choices B, C, and D are incorrect for auscultating the aortic valve. The fifth intercostal space to the left of the sternum is where the mitral valve is best heard, the third intercostal space to the left of the sternum is where the pulmonic valve is best heard, and the fourth intercostal space at the midclavicular line is where the tricuspid valve is best auscultated.

2. A client expresses pain during dressing changes postoperatively. Which intervention should the nurse prioritize?

Correct answer: D

Rationale: The priority action for the nurse is to address the client's immediate physiological need for comfort and pain relief during the dressing change. Administering pain medication 45 minutes before the procedure can help alleviate the pain experienced by the client. Encouraging relaxation techniques (choice A) is beneficial but may not provide sufficient pain relief during the dressing change. Educating about the importance of pain management (choice B) is relevant but does not address the immediate need for pain relief. Assisting the client to a comfortable position (choice C) is helpful but does not directly address the client's pain concern during the dressing change. Administering pain medication is the most direct and effective intervention to ensure optimal client comfort and compliance with necessary procedures.

3. What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?

Correct answer: D

Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.

4. A group of newly licensed nurses is being instructed by a nurse about the responsibilities that organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles?

Correct answer: C

Rationale: The correct answer is 'C: Justice.' Justice in healthcare ethics involves fairness and providing equal treatment to all individuals in similar situations. In this scenario, ensuring that all clients waiting for a kidney transplant meet the same qualifications aligns with the principle of justice by offering equal opportunities for transplantation. Choice A, 'Fidelity,' pertains to keeping promises and being loyal to patients, not the equal treatment of individuals. Choice B, 'Autonomy,' refers to respecting patients' rights to make decisions about their own care, which is not directly related to the equal qualifications for kidney transplants. Choice D, 'Nonmaleficence,' focuses on the obligation to do no harm, which is important in healthcare but not the primary ethical principle demonstrated in this scenario.

5. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

Similar Questions

A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurse's priority?
When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?

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