HESI LPN
HESI PN Exit Exam 2024
1. 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.
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. While caring for a client with an AV fistula in the left forearm, the PN observed a palpable buzzing sensation over the fistula. What action should the PN take?
- A. Loosen the fistula dressing
- 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: A palpable buzzing sensation, known as a thrill, over an AV fistula indicates proper functioning. The correct action for the PN is to document that the fistula is intact. Choice A is incorrect because there is no need to loosen the fistula dressing when the thrill is felt. Choice B is incorrect as a bounding pulse is not related to the observed buzzing sensation. Choice D is incorrect because applying pressure is unnecessary when a thrill is present, indicating proper AV fistula function.
4. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?
- A. Self-Actualization
- B. Intimacy vs. Isolation
- C. Altruism
- D. Purposefulness
Correct answer: A
Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.
5. A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?
- A. Encourage the client to get plenty of exercise in addition to the dietary change
- B. Provide written information about the seven warning signs of cancer
- C. Remind the client to ensure that the dairy products are fortified with Vitamin D
- D. Suggest that an increase in fruits and vegetables is more beneficial
Correct answer: D
Rationale: Increasing fruits and vegetables in the diet is more beneficial in reducing cancer risk due to their high levels of antioxidants and fiber, which help protect against cancer. While exercise is important for overall health, in this context, focusing on fruits and vegetables is more relevant to reducing cancer risk than exercise alone. Providing information about cancer warning signs is not directly addressing the client's dietary choice. While Vitamin D is essential for various health aspects, the primary focus here should be on a diet rich in fruits and vegetables for cancer risk reduction.
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