while providing oral care for a client who is unconscious the nurse positions the client laterally and uses a basin to collect secretions which interv
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2023

1. While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?

Correct answer: B

Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.

2. A client post-thyroidectomy is being monitored for signs of hypocalcemia. Which of the following symptoms should the nurse be most concerned about?

Correct answer: A

Rationale: The correct answer is A: Tingling in the hands and around the mouth. This symptom is a classic sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands were inadvertently damaged during surgery. Nausea and vomiting (Choice B) are not specific to hypocalcemia. Constipation (Choice C) is not a typical symptom of hypocalcemia. Bradycardia (Choice D) is more commonly associated with hypothyroidism rather than hypocalcemia.

3. What is the primary action a healthcare professional should take when a patient with a suspected myocardial infarction (MI) arrives in the emergency department?

Correct answer: B

Rationale: Administering oxygen and obtaining an ECG are crucial initial steps when managing a suspected myocardial infarction (MI). Oxygen helps improve oxygenation to the heart muscle, while an ECG is essential to diagnose an MI promptly. Applying a cold compress, encouraging the patient to walk, or providing a high-carbohydrate meal are not appropriate actions in the initial management of a suspected MI. Applying a cold compress can delay necessary interventions, encouraging the patient to walk may worsen the condition, and providing a high-carbohydrate meal is irrelevant to the immediate needs of a patient with a suspected MI.

4. When a woman in early pregnancy is leaving the clinic, she blushes and asks the nurse if it is true that sex during pregnancy is bad for the baby. What is the best response for the nurse to give?

Correct answer: D

Rationale: Choice D is the best response as it reassures the patient that intercourse in a normal pregnancy will not harm the baby. It also shows empathy by acknowledging that many women experience changes in sexual desire during pregnancy. This response validates the patient's concerns and opens up a dialogue about her feelings. Choice A is incorrect as it lacks information about changes in sexual desire and oversimplifies the situation. Choice B is dismissive of the patient's concerns and does not provide adequate information. Choice C is not the best response as it suggests asking the doctor without offering immediate reassurance or addressing the patient's worries.

5. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

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