HESI LPN
HESI PN Exit Exam
1. A client is post-operative day two from an abdominal surgery and reports feeling weak and lightheaded when attempting to get out of bed. What is the nurse's priority action?
- A. Encourage the client to drink fluids.
- B. Assist the client back to bed and monitor vital signs.
- C. Administer a prescribed antiemetic.
- D. Notify the healthcare provider.
Correct answer: B
Rationale: The nurse's priority action should be to assist the client back to bed and monitor vital signs. The client's symptoms of feeling weak and lightheaded could indicate potential issues like hypotension or dehydration, which need to be assessed promptly. Encouraging fluids (Choice A) could be beneficial but is not the immediate priority. Administering an antiemetic (Choice C) may not address the underlying cause of the client's symptoms. Notifying the healthcare provider (Choice D) can be done after the client has been stabilized and assessed.
2. Based on the principle of asepsis, which situation should the nurse consider to be sterile?
- A. A one-inch border around the edges of a sterile field set up in the operating room
- B. A sterile glove that the nurse thinks might have touched her hair
- C. A wrapped, unopened sterile 4x4 gauze pad placed on a damp tabletop
- D. An open sterile Foley catheter kit set up on a table at the nurse's waist level
Correct answer: D
Rationale: The correct answer is D because an open sterile Foley catheter kit set up at waist level is considered sterile if it has not been contaminated. Choice A is incorrect because the one-inch border around a sterile field is considered non-sterile. Choice B is incorrect because a sterile glove that might have touched the nurse's hair is likely contaminated. Choice C is incorrect because a wrapped, unopened sterile gauze pad placed on a damp tabletop may have become contaminated.
3. Which action should the PN implement when using standard precautions to provide client care?
- A. Apply sterile gloves to obtain a finger stick blood sample
- B. Wear clean exam gloves to perform perineal catheter care
- C. Replace the needle cap after giving an intramuscular injection
- D. Wear a paper gown to prevent transmission of droplet pathogens
Correct answer: B
Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.
4. A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers questions with one or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important for the PN to implement?
- A. Persuade the client to lie down
- B. Provide a drink high in electrolytes
- C. Observe the client during the shift
- D. Measure appropriate vital signs
Correct answer: D
Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.
5. What is the primary function of surfactant in the lungs?
- A. Reduce surface tension
- B. Enhance oxygen absorption
- C. Facilitate carbon dioxide release
- D. Increase lung volume
Correct answer: A
Rationale: The primary function of surfactant in the lungs is to reduce surface tension in the alveoli. This reduction in surface tension prevents lung collapse and allows for easier breathing. It is particularly crucial in premature infants to help with lung expansion. Choice B is incorrect because surfactant primarily affects surface tension, not oxygen absorption. Choice C is incorrect because surfactant's main role is not in facilitating carbon dioxide release. Choice D is incorrect because surfactant does not directly increase lung volume; its main role is in reducing surface tension.
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