Question

The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

Answer 1

Correct Answers:

Coughs over the catheter site while cleansing the skin.

Rationale :

🔷 Coughing over the catheter site exposes the area to airborne pathogens from the mouth and respiratory tract, significantly increasing the risk of peritonitis—a serious infection in clients undergoing peritoneal dialysis.

🔷 The peritoneal dialysis catheter provides direct access to the peritoneal cavity, so maintaining strict aseptic technique during care is essential to avoid bacterial contamination.

🔷 Even if wearing gloves or cleansing properly, talking, sneezing, or coughing near the site compromises sterility and requires re-education on respiratory hygiene and catheter site protection.

🔷 Proper technique should include mask usage and avoiding unnecessary exposure of the site during care procedures.

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Answer 2

Correct Answers:

Oxygen saturation.

Rationale :

🔵 Oxygen saturation provides a direct measurement of the effectiveness of oxygen therapy and the client’s current oxygenation status. Before discontinuing supplemental oxygen, the PN must assess whether the client can maintain adequate oxygen levels without support.

🔵 Clients receiving oxygen via nasal cannula often have PRN orders, meaning oxygen use depends on clinical need. The saturation level (typically measured via pulse oximetry) helps determine if it's safe to reduce or remove oxygen.

🔵 A value of ≥ 95% on room air is generally considered acceptable in most clients. If the level is borderline or low, oxygen removal could result in hypoxia.

🔵 While other vitals like heart rate, blood pressure, and breath sounds offer useful information, they do not specifically assess oxygenation and cannot replace pulse oximetry for this decision.

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Answer 3

Correct Answers:

Stay well rested and avoid a large caffeine intake.
Avoid flashing lights and excessive visual stimuli.
Seek a safe place if sensing dizziness or sensory disturbances.

Rationale :

Stay well rested and avoid a large caffeine intake

🌙 Sleep deprivation significantly increases the risk of seizure activity by disrupting normal brain function.

🌙 Clients with seizure disorders should maintain a consistent sleep routine and avoid all-nighters.

🌙 Caffeine acts as a central nervous system stimulant, which can potentially lower the seizure threshold.

🌙 Educating the client to limit or avoid caffeine (e.g., coffee, energy drinks) can help prevent episodes.

✅ C. Avoid flashing lights and excessive visual stimuli

💡 Flashing or flickering lights are a well-known trigger for photosensitive seizures, especially in adolescents.

💡 Clients should avoid exposure to strobe lights, flashing screens, and certain video games.

💡 Using blue-light filters or sunglasses may help reduce risk in stimulating environments.

💡 Families should be educated on managing home environments to minimize visual triggers.

✅ D. Seek a safe place if sensing dizziness or sensory disturbances

🛡️ Many clients experience auras—early warning signs like dizziness, strange smells, or visual changes—before a seizure.

🛡️ If an aura is recognized, the client should sit or lie down in a safe area to prevent injury.

🛡️ Prompt action can reduce the likelihood of injury during a generalized or complex partial seizure.

🛡️ Reinforce the importance of safety-first behaviors when unusual sensations occur.

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Answer 4

Correct Answers:

Driving a car.

Rationale :

🚗 Driving is typically restricted after a transurethral resection of the prostate (TURP) until cleared at the first postoperative visit.

🚗 This limitation helps reduce the risk of strain, bleeding, or impaired response due to pain or lingering effects of anesthesia or narcotics.

🚗 Sudden movements or the need to brake quickly can place stress on the surgical area, potentially leading to complications like hematuria.

🚗 Clients are usually advised to avoid operating machinery or driving until they are fully mobile, alert, and no longer taking opioids.

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Answer 5

Correct Answers:

Stop the blood infusion.

Rationale :

🛑 Shaking, nausea, and vomiting during a blood transfusion are potential signs of a transfusion reaction, which can be life-threatening.

🛑 The first and most critical action is to immediately stop the transfusion to prevent further exposure to the incompatible or contaminated blood product.

🛑 After stopping the infusion, the PN should maintain IV access with 0.9% sodium chloride, notify the healthcare provider, and monitor vital signs.

🛑 Further actions include returning the blood bag and tubing to the lab and completing transfusion reaction protocols.

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Answer 6

Correct Answers:

Use penlight to assess pharynx for bleeding.

Rationale :

🔦 Repeated swallowing after rhinoplasty may indicate posterior nasal bleeding, even if external bleeding is not visible.

🔦 The priority action is to inspect the oropharynx using a penlight for signs of blood trickling down the throat, which could lead to aspiration or airway compromise.

🔦 This type of bleeding is not always visible externally and must be identified promptly to prevent complications.

🔦 Early detection allows the healthcare team to take immediate action to control bleeding and ensure airway safety.

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Answer 7

Correct Answers:

Measure intake and output while straining all urine.

Rationale :

⚖️ Straining all urine is the top priority to detect passage of kidney stones and identify their composition for appropriate treatment planning.

⚖️ Documenting intake and output (I&O) provides essential information about renal function and hydration status, which directly impacts stone formation and elimination.

⚖️ Capturing any passed stones allows laboratory analysis to determine if they are calcium oxalate, uric acid, or other types, guiding further dietary or pharmacologic management.

⚖️ This intervention helps monitor treatment effectiveness and supports safe recovery during acute stone episodes.

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Answer 8

Correct Answers:

Obtain manual BP readings with a cuff on the left arm.

Rationale :

🩺 Blood pressure should never be taken on the side of a mastectomy (right arm in this case) due to the risk of lymphedema, which can be triggered by even minor trauma or compression.

🩺 The left arm is preferred in this scenario, even with a cast, provided there’s no vascular compromise and the site is accessible.

🩺 Manual BP measurement is safer and allows for more control over inflation and pressure application, especially near a cast.

🩺 Taking BP on the correct limb ensures accurate monitoring while protecting the affected side from complications.

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Answer 9

Correct Answers:

Blood cell counts.

Rationale :

🧬 Chemotherapy commonly causes bone marrow suppression, which can lead to neutropenia, anemia, and thrombocytopenia.

🧬 Monitoring blood cell counts (CBC with differential) is the priority assessment to detect life-threatening conditions such as infection, bleeding, or hypoxia.

🧬 Two weeks after chemotherapy, nadir levels (lowest point of WBCs, especially neutrophils) are often reached, increasing risk for complications.

🧬 Prompt recognition of low WBC, RBC, or platelet counts allows for timely interventions such as isolation precautions, transfusions, or colony-stimulating factors.

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Answer 10

Correct Answers:

80/60 mm Hg.

Rationale :

🛑 A blood pressure of 80/60 mm Hg is considered hypotensive and may indicate inadequate perfusion to vital organs.

🛑 Symptoms such as dizziness, weakness, fainting, or shock may follow if not promptly assessed and managed.

🛑 This value requires immediate evaluation to determine the cause (e.g., dehydration, medication effect, cardiac issues) and ensure client safety.

🛑 Compared to elevated readings, critically low BP poses a more urgent risk of collapse or organ hypoperfusion in a community setting.

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Hesi Specialiaty-LPN Med Surg Exam.

No.

1 :
The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

2 :
A client has a PRN prescription for a nasal cannula at 2 to 3 L/minute. The client is wearing a nasal cannula at 2 L/minute and asks the practical nurse (PN) if it can be removed. Which client data is most important for the PN to obtain before responding to the client?

3 :
A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. What information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.

4 :
A client is recovering from a transurethral prostatectomy. Which activity should the practical nurse (PN) reinforce with the client to limit until after the first postoperative visit?

5 :
A client is receiving a unit of packed red blood cells (PRBCs). Which is the first action the practical nurse (PN) should take if the client begins to shake and reports feelings of nausea and vomiting?

6 :
Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

7 :
An obese client is admitted for treatment of kidney stones. Which action by the practical nurse (PN) takes priority?

8 :
A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?

9 :
A client with breast cancer who received chemotherapy two weeks ago returns to the clinic for follow-up. Which priority follow-up assessment should the practical nurse (PN) anticipate for this client?

10 :
The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?

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Hesi Specialiaty-LPN Med Surg Exam.

No.

1 : The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

2 : A client has a PRN prescription for a nasal cannula at 2 to 3 L/minute. The client is wearing a nasal cannula at 2 L/minute and asks the practical nurse (PN) if it can be removed. Which client data is most important for the PN to obtain before responding to the client?

3 : A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. What information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.

4 : A client is recovering from a transurethral prostatectomy. Which activity should the practical nurse (PN) reinforce with the client to limit until after the first postoperative visit?

5 : A client is receiving a unit of packed red blood cells (PRBCs). Which is the first action the practical nurse (PN) should take if the client begins to shake and reports feelings of nausea and vomiting?

6 : Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

7 : An obese client is admitted for treatment of kidney stones. Which action by the practical nurse (PN) takes priority?

8 : A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?

9 : A client with breast cancer who received chemotherapy two weeks ago returns to the clinic for follow-up. Which priority follow-up assessment should the practical nurse (PN) anticipate for this client?

10 : The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?

1 :
The practical nurse (PN) is assisting a client who is performing peritoneal dialysis catheter self-care before being discharged home. Which behavior indicates that the client needs additional teaching?

2 :
A client has a PRN prescription for a nasal cannula at 2 to 3 L/minute. The client is wearing a nasal cannula at 2 L/minute and asks the practical nurse (PN) if it can be removed. Which client data is most important for the PN to obtain before responding to the client?

3 :
A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. What information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply.

4 :
A client is recovering from a transurethral prostatectomy. Which activity should the practical nurse (PN) reinforce with the client to limit until after the first postoperative visit?

5 :
A client is receiving a unit of packed red blood cells (PRBCs). Which is the first action the practical nurse (PN) should take if the client begins to shake and reports feelings of nausea and vomiting?

6 :
Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

7 :
An obese client is admitted for treatment of kidney stones. Which action by the practical nurse (PN) takes priority?

8 :
A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?

9 :
A client with breast cancer who received chemotherapy two weeks ago returns to the clinic for follow-up. Which priority follow-up assessment should the practical nurse (PN) anticipate for this client?

10 :
The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?