while caring for a client with an av fistula in the left forearm the nurse observed a palpable buzzing sensation over the fistula what action should t
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2024

1. While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?

Correct answer: C

Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.

2. A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.

3. Which task could the PN safely delegate to the UAP?

Correct answer: A

Rationale: The correct answer is A because oral feeding of a child is a task that can be safely delegated to an unlicensed assistive personnel (UAP). This task involves providing basic care and does not require specialized nursing skills. Choices B, C, and D involve assessments, recording client goals, and evaluating pain, respectively, which all require specialized nursing knowledge, judgment, and skills. These tasks are not within the scope of practice for a UAP.

4. A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti-tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP?

Correct answer: B

Rationale: The correct answer is B: Gentamicin 160 mg IM daily. Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity, leading to ringing in the ears (tinnitus). This symptom should be reported to the HCP immediately, as it may indicate a need to adjust or discontinue the medication. Choice A, Pyridoxine with a B complex multivitamin, is not the cause of ototoxicity. Choices C and D, Rifampin and Isoniazid, are anti-tubercular medications but are not associated with causing ringing in the ears.

5. What is the function of the enzyme lactase in the digestive system?

Correct answer: A

Rationale: The correct answer is A: 'Breaks down lactose into glucose and galactose.' Lactase is an enzyme in the small intestine that specifically breaks down lactose, the sugar found in milk, into glucose and galactose for absorption. Choice B is incorrect because proteins are broken down into amino acids by protease enzymes. Choice C is incorrect because the enzyme amylase converts starch into maltose. Choice D is incorrect as lipase enzymes break down fats into fatty acids.

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