PN HESI Exit V2 EXAM 160 Questions with Answers 100%
Accuracy
1. The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery.
The nurse plans to do which to enable the client to best tolerate the ambulation?
1. Provide the client with a walker.
2. Remove the telemetry equipment.
3. Encourage the client to cough and deep breathe.
4. Premedicate the client with an analgesic before ambulating.
2. A client is wearing a continuous cardiac monitor, which begins to alarm at the
nurse's station. The nurse sees no electrocardiographic complexes on the screen.
The nurse should do which first?
a. Call a code blue.
b. Call the health care provider.
c. Check the client status and lead placement.
d. Press the recorder button on the ECG console.
3. 3) The LPN/LVN in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse
suspects pulmonary edema. The nurse immediately notifies the registered nurse
and expects which interventions to be
Administering oxygen prescribed? Select all that apply. a.
b. Inserting a Foley catheter
c. Administering furosemide (Lasix)
d. Administering morphine sulfate intravenously
e. Transporting the client to the coronary care unit
f. Placing the client in a low-Fowler's side-lying position
4. The nurse is monitoring a client following cardioversion.
pg. 1
, Which observations should be of highest priority to the nurse?
a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness
5. The nurse is assisting in caring for the client immediately after insertion of a
permanent demand pacemaker via the right subclavian vein. The nurse prevents
dislodgement of the pacing catheter by implementing which intervention?
a. Limiting movement and abduction of the left arm
b. Limiting movement and abduction of the right arm
c. Assisting the client to get out of bed and ambulate with a walker 4. Having the
physical therapist do active range of motion to the right arm
6. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest
pain and shortness of breath, and the client is visibly anxious. The LPN/LVN
understands that a life-threatening complication of this condition is which?
a. Pneumonia
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction
7. A 24-year-old man seeks medical attention for complaints of claudication in the
arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg.
The nurse should check the client for which next?
a. Smoking history
b. Recent exposure to allergens
c. History of recent insect bites
d. Familial tendency toward peripheral vascular disease
pg. 2
,8. The nurse has reinforced instructions to the client with Raynaud's disease about
self-management of the disease process. The nurse determines that the client
needs further teaching if the client states which?
a. "Smoking cessation is very important."
b. "Moving to a warmer climate should help."
c. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine
(Procardia) as prescribed will decrease vessel spasm."
9. A client with myocardial infarction suddenly becomes tachycardic, shows signs of
air hunger, and begins coughing frothy, pink- tinged sputum. The nurse listens to
breath sounds, expecting to hear which breath sounds bilaterally?
a. Rhonchi
b. Crackles
c. Wheezes
d. Diminished breath sounds
10. The LPN/LVN is collecting data on a client with a diagnosis of right sided heart
failure. The nurse should expect to note which specific characteristic of this
condition?
a. Dyspnea
b. Hacking cough
c. Dependent edema
d. Crackles on lung auscultation
11. The LPN/LVN is checking the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. The nurse interprets that the
neurovascular status is which?
a. Moderately impaired, and the surgeon should be called
b. Normal, caused by increased blood flow through the leg
c. Slightly deteriorating, and should be monitored for another hour
d. Adequate from an arterial approach, but venous complications are arising
pg. 3
, 12. A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the
health care provider is going to perform carotid massage.
The LPN/LVN responds that this procedure may stimulate which?
a. Vagus nerve to slow the heart rate
b. Vagus nerve to increase the heart rate
c. Diaphragmatic nerve to slow the heart rate
d. Diaphragmatic nerve to increase the heart rate
13. A client is admitted to the hospital with possible rheumatic endocarditis. The
LPN/LVN should check for a history of which type of infection?
a. Viral infection
b. Yeast infection
c. Streptococcal infection
d. Staphylococcal infection
14. A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The
LPN/LVN notes that the client's toes are mottled,
and cool and the client verbalizes some numbness and tingling of the foot. Which
interpretation should the nurse make of these findings?
a. The boot has not yet dried.
b. The boot is controlling leg edema.
c. The boot is impairing venous return.
d. The boot has been applied too tightly.
15. A client with angina complains that the anginal pain is prolonged and severe and
occurs at the same time each day, most often in the morning. On further data
collection, the nurse notes that the pain occurs in the absence of precipitating
factors. How should the LPN/LVN best describe this type of anginal pain?
a. Stable angina
pg. 4
Accuracy
1. The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery.
The nurse plans to do which to enable the client to best tolerate the ambulation?
1. Provide the client with a walker.
2. Remove the telemetry equipment.
3. Encourage the client to cough and deep breathe.
4. Premedicate the client with an analgesic before ambulating.
2. A client is wearing a continuous cardiac monitor, which begins to alarm at the
nurse's station. The nurse sees no electrocardiographic complexes on the screen.
The nurse should do which first?
a. Call a code blue.
b. Call the health care provider.
c. Check the client status and lead placement.
d. Press the recorder button on the ECG console.
3. 3) The LPN/LVN in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse
suspects pulmonary edema. The nurse immediately notifies the registered nurse
and expects which interventions to be
Administering oxygen prescribed? Select all that apply. a.
b. Inserting a Foley catheter
c. Administering furosemide (Lasix)
d. Administering morphine sulfate intravenously
e. Transporting the client to the coronary care unit
f. Placing the client in a low-Fowler's side-lying position
4. The nurse is monitoring a client following cardioversion.
pg. 1
, Which observations should be of highest priority to the nurse?
a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness
5. The nurse is assisting in caring for the client immediately after insertion of a
permanent demand pacemaker via the right subclavian vein. The nurse prevents
dislodgement of the pacing catheter by implementing which intervention?
a. Limiting movement and abduction of the left arm
b. Limiting movement and abduction of the right arm
c. Assisting the client to get out of bed and ambulate with a walker 4. Having the
physical therapist do active range of motion to the right arm
6. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest
pain and shortness of breath, and the client is visibly anxious. The LPN/LVN
understands that a life-threatening complication of this condition is which?
a. Pneumonia
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction
7. A 24-year-old man seeks medical attention for complaints of claudication in the
arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg.
The nurse should check the client for which next?
a. Smoking history
b. Recent exposure to allergens
c. History of recent insect bites
d. Familial tendency toward peripheral vascular disease
pg. 2
,8. The nurse has reinforced instructions to the client with Raynaud's disease about
self-management of the disease process. The nurse determines that the client
needs further teaching if the client states which?
a. "Smoking cessation is very important."
b. "Moving to a warmer climate should help."
c. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine
(Procardia) as prescribed will decrease vessel spasm."
9. A client with myocardial infarction suddenly becomes tachycardic, shows signs of
air hunger, and begins coughing frothy, pink- tinged sputum. The nurse listens to
breath sounds, expecting to hear which breath sounds bilaterally?
a. Rhonchi
b. Crackles
c. Wheezes
d. Diminished breath sounds
10. The LPN/LVN is collecting data on a client with a diagnosis of right sided heart
failure. The nurse should expect to note which specific characteristic of this
condition?
a. Dyspnea
b. Hacking cough
c. Dependent edema
d. Crackles on lung auscultation
11. The LPN/LVN is checking the neurovascular status of a client who returned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. The nurse interprets that the
neurovascular status is which?
a. Moderately impaired, and the surgeon should be called
b. Normal, caused by increased blood flow through the leg
c. Slightly deteriorating, and should be monitored for another hour
d. Adequate from an arterial approach, but venous complications are arising
pg. 3
, 12. A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the
health care provider is going to perform carotid massage.
The LPN/LVN responds that this procedure may stimulate which?
a. Vagus nerve to slow the heart rate
b. Vagus nerve to increase the heart rate
c. Diaphragmatic nerve to slow the heart rate
d. Diaphragmatic nerve to increase the heart rate
13. A client is admitted to the hospital with possible rheumatic endocarditis. The
LPN/LVN should check for a history of which type of infection?
a. Viral infection
b. Yeast infection
c. Streptococcal infection
d. Staphylococcal infection
14. A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The
LPN/LVN notes that the client's toes are mottled,
and cool and the client verbalizes some numbness and tingling of the foot. Which
interpretation should the nurse make of these findings?
a. The boot has not yet dried.
b. The boot is controlling leg edema.
c. The boot is impairing venous return.
d. The boot has been applied too tightly.
15. A client with angina complains that the anginal pain is prolonged and severe and
occurs at the same time each day, most often in the morning. On further data
collection, the nurse notes that the pain occurs in the absence of precipitating
factors. How should the LPN/LVN best describe this type of anginal pain?
a. Stable angina
pg. 4
