what is the first step in using an automated external defibrillator aed on a patient who has collapsed
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. 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.

2. 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.

3. You have a patient who has just had a diagnostic arthroscopy. You are instructing him about what to do when he gets home. Which of the following would you NOT instruct him to do?

Correct answer: A

Rationale: Patients should rest and avoid normal activities for a short period after arthroscopy to allow healing and prevent swelling, which could worsen with early activity. Elevation and icing are recommended post-procedure to reduce swelling and pain. Instructing the patient to resume normal activities within 12 hours could lead to increased swelling and delayed healing. Reporting severe pain is crucial as it could indicate a complication. Therefore, the correct instruction is not to resume normal activities immediately after arthroscopy.

4. A client is admitted to the postoperative surgical unit with two test tubes after a left lobectomy. The nurse observed that the chambers are set at the prescribed suction of 20 cm water pressure, and tidying occurs with respirations and bubbling. What action should the nurse implement?

Correct answer: C

Rationale: Maintaining system integrity is essential to promote lung reexpansion in postoperative patients with chest tubes. Clamping the chest tube abruptly can lead to tension pneumothorax, a life-threatening condition. The bubbling observed is a normal sign indicating that the system is functioning correctly, as it allows the drainage of air or fluid from the pleural space. Notifying the registered nurse may be necessary if there are significant concerns or changes observed, but the immediate action should be to ensure system integrity and lung reexpansion.

5. Which laboratory value is most important to monitor for a patient receiving heparin therapy?

Correct answer: C

Rationale: The correct answer is C, Partial thromboplastin time (PTT). PTT is monitored to assess the therapeutic effect of heparin therapy. It helps ensure that the heparin levels are within the desired range to prevent either clotting or excessive bleeding. Platelet count (A) is important but does not directly assess heparin's therapeutic effect. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor patients on warfarin, not heparin therapy.

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