HESI LPN
HESI PN Exit Exam 2024
1. What dietary considerations must the nurse keep in mind for a patient who is an Orthodox Jew?
- A. They can eat any food unless it is Yom Kippur
- B. They cannot mix meat and dairy
- C. They cannot eat meat on Ash Wednesday
- D. They are vegetarian
Correct answer: B
Rationale: Orthodox Jews follow dietary laws (Kashrut) that prohibit mixing meat and dairy products in the same meal. This restriction is known as 'not mixing milk and meat.' Therefore, choice B is the correct answer. Choices A, C, and D are incorrect because being an Orthodox Jew does not mean they can eat any food unless it is Yom Kippur, avoid meat on Ash Wednesday, or are necessarily vegetarian.
2. An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the nurse?
- A. No bowel movement for two days
- B. Mother assists child in changing positions
- C. Weights are touching the foot of the bed
- D. Child is able to move the toes freely when tickled
Correct answer: C
Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.
3. A client who had a left hemicolectomy is experiencing a low-grade fever on post-operative day three. What is the nurse's best action?
- A. Encourage deep breathing and the use of the incentive spirometer.
- B. Administer antipyretic medication as prescribed.
- C. Notify the healthcare provider immediately.
- D. Increase the client’s fluid intake.
Correct answer: A
Rationale: A low-grade fever on post-operative day three can be a sign of atelectasis, a common post-operative complication. Encouraging deep breathing and the use of the incentive spirometer can help prevent and treat this condition. Atelectasis is often due to shallow breathing, so option A is the best initial action to promote lung expansion. Administering antipyretic medication (option B) may help reduce the fever but does not directly address the underlying cause. Notifying the healthcare provider immediately (option C) is not necessary at this point unless other concerning symptoms are present. Increasing the client’s fluid intake (option D) is important for overall recovery but is not the priority in this scenario.
4. The nurse is preparing to provide wound care for a client. Which step should be done first?
- A. Don procedural gloves
- B. Remove the dressing
- C. Apply prescribed medications to the wound
- D. Don a pair of sterile gloves
Correct answer: A
Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.
5. While caring for a client with an AV fistula in the left forearm, the nurse observed a palpable buzzing sensation over the fistula. What action should the nurse take?
- A. Loosen the dressing of the fistula
- B. Report the presence of a bounding pulse
- C. Document that the fistula is intact
- D. Apply gentle pressure over the site
Correct answer: C
Rationale: The correct answer is C: Document that the fistula is intact. The palpable buzzing sensation (known as a thrill) over the AV fistula indicates proper functioning. It is essential for the nurse to document this finding to ensure ongoing monitoring of the fistula's status. Choices A, B, and D are incorrect. Choice A is incorrect because there is no indication to loosen the dressing. Choice B is incorrect as a bounding pulse is not associated with the palpable buzzing sensation of a thrill. Choice D is incorrect as applying pressure over the site is not necessary for this situation.
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