Practice Question
An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?
Answer Choices:
Correct Answer:
Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.
Rationale:
💠 Frequent monitoring helps prevent falls and injury while avoiding unnecessary restraint.
💠 Postoperative clients may become delirious due to pain, medication, or unfamiliar environments.
💠 Keeping the side rails up is a non-restrictive safety intervention that protects the client.
💠 Delegating checks every 15 minutes ensures early detection of agitation recurrence.
💠 This action supports client-centered care while allowing time for the pain medication to take effect.
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This question is from LPN HESI Exit-2023 Exam 2 which contains 71 questions.
More Questions from This Exam
The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?
Answer Choices:
A. Demonstrate how to administer medication via a feeding tube.
B. Confirm that the medication is only administered once daily.
C. Determine if the medication is compatible with the solution.
D. Offer to assist in calculating the rate of flow for the mixture.
A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not understand how awful it is. I am a burden to my family because I cannot hold a job. I do not know how much longer I can live this way." Which information is most important for the practical nurse (PN) to ask in response to the client's statements?
Answer Choices:
A. Question about which rituals are most often used to reduce anxiety.
B. Ask if the obsessions and compulsions interfere with sleep.
C. Inquire if the distress could lead to considering suicide as an option.
D. Determine what makes the client think people are laughing.
Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)
Answer Choices:
A. Palpate the rate and volume of the pulse.
B. Check fingernails for the presence of clubbing.
C. Measure body weight at the same time daily.
D. Observe the color and amount of urine.
E. Compare muscle strength of both arms.
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?
Answer Choices:
A. Obtain a 30 mL syringe and a vial of sterile water.
B. Ask the client if she has previously been catheterized.
C. Consult with the charge nurse about the catheter.
D. Position the client and observe the urinary meatus.
The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds (4,581 grams). The infant is jittery and has a heel stick glucose level of 40 mg/dL (2.2 mmol/L) 30 minutes after birth. Based on this information, which intervention should the practical nurse (PN) implement first ?Reference range: Blood glucose neonate: [30 to 60 mg/dL or 1.7 to 3.3 mmol/L]
Answer Choices:
A. Offer nipple feedings of 10% dextrose.
B. Begin frequent feedings of breast milk or formula.
C. Repeat the heel stick for glucose in one hour.
D. Assess for signs of hypocalcemia.
Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN HESI Exit Exam(s)
- Domain: LPN HESI Exit-2023
- Answer Choices: 4