HESI LPN
HESI PN Exit Exam
1. The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?
- A. Swollen and discolored penile shaft
- B. Prepuce extends over the head of the penis
- C. Leaking urine around the top of the catheter
- D. Moist and excoriated perineal skin folds
Correct answer: A
Rationale: The correct answer is A: Swollen and discolored penile shaft. Swelling and discoloration of the penile shaft may indicate an infection or other complications requiring immediate attention. Prompt reporting allows for timely intervention to prevent further harm to the client. Choice B is incorrect because the prepuce extending over the head of the penis is not an urgent issue. Choice C, leaking urine around the catheter, may require intervention but is not as urgent as the swelling and discoloration described in choice A. Choice D, moist and excoriated perineal skin folds, also needs attention but is not as concerning as the potential complications indicated by the findings in choice A.
2. A client is recovering from abdominal surgery and has a nasogastric (NG) tube in place. The nurse notes that the client is experiencing nausea despite the NG tube being patent. What is the nurse's best action?
- A. Increase the suction on the NG tube.
- B. Administer an antiemetic as prescribed.
- C. Irrigate the NG tube with saline.
- D. Reposition the client to the left side.
Correct answer: B
Rationale: Administering an antiemetic as prescribed is the best action for the nurse to take when a client with a patent NG tube is experiencing nausea. This intervention can help relieve nausea effectively. Increasing suction on the NG tube (Choice A) may not address the underlying cause of the nausea and could potentially lead to complications. Irrigating the NG tube with saline (Choice C) is not indicated for addressing nausea in this scenario. Repositioning the client to the left side (Choice D) is not the priority intervention for nausea in a client with a patent NG tube.
3. What is the function of the epiglottis during swallowing?
- A. Prevents food from entering the trachea
- B. Aids in food propulsion
- C. Enhances taste sensation
- D. Lubricates the esophagus
Correct answer: A
Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.
4. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?
- A. Due date
- B. Blood pressure
- C. Gravida and parity
- D. Fundal height
Correct answer: B
Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.
5. 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.
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