what intervention should the pn implement when taking the rectal temperature of an adult client
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Nursing Elites

HESI LPN

HESI PN Exit Exam

1. What intervention should the PN implement when taking the rectal temperature of an adult client?

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

2. What is the best thing to say to a patient scheduled for cataract surgery who is concerned that the physician works on the correct eye?

Correct answer: D

Rationale: The best response reassures the patient by explaining the process of verifying and marking the correct eye, a safety measure to prevent wrong-site surgery, directly addressing the patient’s concern. Choice A is close but implies the ID bracelet alone determines the correct eye, missing the verification process. Choice B talks about confirmation but lacks details about marking the correct eye. Choice C mentions the surgeon's record but does not specify the direct verification and marking process, unlike Choice D.

3. What is the first step in using an automated external defibrillator (AED) on a patient who has collapsed?

Correct answer: B

Rationale: The correct answer is B: Turn on the AED and follow the voice prompts. This is the first step in using an AED as the device will guide you through the process of analyzing the heart rhythm and delivering a shock if necessary. Choice A, applying the pads to the chest, comes after turning on the AED. Checking the patient's pulse (Choice C) is not necessary before using an AED as the device is specifically designed to assess the need for defibrillation. Ensuring the area is clear (Choice D) is important for safety but is not the initial step in using an AED.

4. Which of the following components of nutrition has a primary function of helping with tissue growth and repair?

Correct answer: C

Rationale: Protein is the correct answer as it is essential for tissue growth and repair. Proteins are composed of amino acids, the building blocks of body tissues. While vitamins D and E have important roles in the body, they are not primarily responsible for tissue growth and repair. Fats are crucial for various bodily functions, like providing energy, but they are not the primary component involved in tissue growth and repair.

5. The practical nurse is caring for a client whose urine drug screen is positive for cocaine. Which behavior is this client likely to exhibit during cocaine withdrawal?

Correct answer: D

Rationale: The correct answer is D: Powerful craving for more. During cocaine withdrawal, individuals often experience intense cravings for the drug, along with symptoms such as fatigue, depression, and anxiety. These cravings can be overpowering and lead to a strong desire to seek out more cocaine to alleviate the withdrawal symptoms. Choices A, B, and C are incorrect as elevated energy level, euphoria, and high self-esteem are more associated with the effects of cocaine rather than withdrawal symptoms. Withdrawal from cocaine is characterized by the opposite, such as fatigue, low mood, and intense cravings.

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