HESI LPN
HESI PN Exit Exam 2023
1. A client post-coronary artery bypass graft (CABG) surgery is concerned about the risk of infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
- A. Avoid touching the incision sites with bare hands.
- B. Take all prescribed antibiotics as directed.
- C. Report any signs of infection to the healthcare provider immediately.
- D. Keep the incision sites clean and dry.
Correct answer: D
Rationale: The correct answer is D: 'Keep the incision sites clean and dry.' After CABG surgery, maintaining the cleanliness and dryness of the incision sites is crucial to prevent infections. This practice reduces the risk of introducing harmful microorganisms to the surgical wound, promoting healing and preventing complications. Option A, while important, does not fully encompass the preventive measures necessary to avoid infections post-surgery. Option B is significant if antibiotics are prescribed, but ensuring cleanliness directly addresses infection prevention. Option C is reactive and focuses on addressing infection after it occurs, rather than proactively preventing it.
2. A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
- A. Take all prescribed antibiotics as directed.
- B. Avoid crowded places and people who are sick.
- C. Wash hands frequently and practice good hygiene.
- D. Keep the surgical site clean and dry.
Correct answer: C
Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.
3. A client reports being able to swallow only small bites of solid food and liquids for the last 3 months. The PN should assess the client for what additional information?
- A. Past traumatic injury to the neck
- B. Daily consumption of hot beverages
- C. History of alcohol or tobacco use
- D. Daily dietary intake of roughage
Correct answer: C
Rationale: The correct answer is C: History of alcohol or tobacco use. A history of alcohol or tobacco use is significant as both are risk factors for esophageal cancer or other esophageal disorders that could cause difficulty swallowing (dysphagia). This information helps in evaluating the underlying cause of the symptom. Choices A, B, and D are less relevant in this context. While a past traumatic injury to the neck could potentially cause swallowing difficulties, given the chronic nature of the symptom in this case, it is more important to focus on potential risk factors associated with esophageal disorders like alcohol and tobacco use. Daily consumption of hot beverages and daily dietary intake of roughage are less likely to be directly related to the client's current swallowing issue.
4. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?
- A. Altered sensory perception
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.
5. A client is recovering from a right-sided mastectomy and is concerned about lymphedema. What should the nurse include in the discharge teaching to minimize this risk?
- A. Encourage wearing tight clothing on the affected arm.
- B. Advise against lifting heavy objects with the affected arm.
- C. Recommend the client sleep on the affected side.
- D. Suggest frequent massage of the affected arm.
Correct answer: B
Rationale: The correct answer is B: Advise against lifting heavy objects with the affected arm. Lifting heavy objects with the affected arm can increase the risk of lymphedema. It is important for clients to avoid activities that strain the affected arm to minimize the risk of developing lymphedema. Choices A, C, and D are incorrect because wearing tight clothing on the affected arm, sleeping on the affected side, and frequent massage of the affected arm can potentially worsen lymphedema or impede the recovery process. Tight clothing can impede lymphatic flow, sleeping on the affected side can restrict circulation, and frequent massage can exacerbate swelling in the arm.
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