HESI LPN
HESI PN Exit Exam
1. 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.
2. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?
- A. The client's bladder for distension.
- B. The IV catheter insertion site.
- C. The patency of the urinary catheter.
- D. The client's vital signs.
Correct answer: C
Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.
3. For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?
- A. The client will ambulate with assistance every 4 hours
- B. The physical therapist will instruct the client in the use of a walker
- C. The client will use self-affirmation statements to decrease fear
- D. The nurse will place a gait belt on the client prior to ambulation
Correct answer: C
Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice B) and placing a gait belt on the client (choice D) are interventions that may be helpful but do not directly address the client's fear of falling.
4. 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.
5. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?
- A. Avoid lifting heavy objects for at least a week.
- B. Follow a low-fat diet.
- C. Monitor the incision sites for signs of infection.
- D. Resume normal activities as tolerated.
Correct answer: C
Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.
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