HESI LPN
HESI PN Exit Exam 2024
1. When teaching a patient with diabetes about foot care, which of the following should the nurse emphasize?
- A. Avoid soaking feet daily to prevent dryness and skin breakdown
- B. Select well-fitting shoes to prevent injury
- C. Trim toenails straight across and file the edges
- D. Avoid using heating pads to prevent burns
Correct answer: C
Rationale: The correct answer is C. Trimming toenails straight across and filing the edges is crucial in diabetic foot care to prevent ingrown toenails and foot injuries. Soaking feet daily can lead to dryness and skin breakdown, increasing the risk of infection. Selecting well-fitting shoes is important to prevent pressure points and skin damage, not tight-fitting shoes. Using heating pads can result in burns or injuries due to decreased sensation in diabetic feet, so it's essential to avoid them.
2. Which nursing intervention is most appropriate for managing delirium in an elderly patient?
- A. Keeping the room brightly lit
- B. Administering sedatives as needed
- C. Encouraging family presence
- D. Restricting fluids
Correct answer: C
Rationale: Encouraging family presence is the most appropriate intervention for managing delirium in elderly patients. This intervention provides orientation, reassurance, and comfort, which can help reduce confusion and anxiety, thus aiding in managing delirium. Keeping the room brightly lit (Choice A) may worsen delirium as it can disrupt the patient's sleep-wake cycle. Administering sedatives (Choice B) should be avoided unless absolutely necessary due to the risk of worsening delirium. Restricting fluids (Choice D) is not a recommended intervention for managing delirium, as hydration is important for overall patient well-being.
3. What is the priority intervention for a patient experiencing an acute asthma attack?
- A. Administering a bronchodilator
- B. Encouraging the patient to drink fluids
- C. Applying a high-flow oxygen mask
- D. Performing chest physiotherapy
Correct answer: A
Rationale: Administering a bronchodilator is the priority intervention in an acute asthma attack. Bronchodilators help to quickly open the airways, relieve bronchospasm, and improve breathing. Encouraging the patient to drink fluids may be beneficial for other conditions but is not the priority in an acute asthma attack. Applying a high-flow oxygen mask may be necessary in severe cases of respiratory distress but is not the initial priority when managing an acute asthma attack. Performing chest physiotherapy is not indicated as the primary intervention for an acute asthma attack and may not address the immediate need to open the airways and improve breathing.
4. A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse’s best action?
- A. Administer a prescribed laxative.
- B. Encourage the client to increase fluid intake.
- C. Auscultate bowel sounds.
- D. Notify the healthcare provider.
Correct answer: C
Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.
5. Which type of isolation precaution is required for a patient with tuberculosis (TB)?
- A. Droplet precautions
- B. Contact precautions
- C. Airborne precautions
- D. Standard precautions
Correct answer: C
Rationale: The correct answer is C: Airborne precautions. Tuberculosis (TB) is transmitted via airborne particles, thus requiring airborne precautions to prevent the spread of infection. This includes using an N95 respirator to filter out small infectious particles. Droplet precautions (Choice A) are used for diseases that spread through large respiratory droplets. Contact precautions (Choice B) are for direct or indirect contact with the patient or their environment. Standard precautions (Choice D) are used for all patients to prevent the spread of infection through blood, bodily fluids, non-intact skin, and mucous membranes.
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