HESI LPN
HESI PN Exit Exam 2024
1. 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.
2. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?
- A. Apply a pulse oximeter
- B. Measure blood pressure
- C. Notify the charge nurse
- D. Observe pressure areas
Correct answer: C
Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.
3. At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score?
- A. 4
- B. 6
- C. 8
- D. 10
Correct answer: C
Rationale: The Apgar score is based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a heart rate over 100 (2 points), is crying (2 points indicating good respiratory effort), resists the catheter (2 points for good reflex irritability), but has acrocyanosis (partial point deduction of 1). Thus, the Apgar score at one minute after birth would be 8. Choice A is incorrect as the given signs indicate a higher score. Choice B is incorrect as the signs described support a score above 6. Choice D is incorrect as it represents a perfect score which is not the case here due to acrocyanosis.
4. 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.
5. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?
- A. Protect the client's feet from injury
- B. Apply a heating pad to affected area
- C. Keep the client's feet elevated
- D. Assess the feet and legs for jaundice
Correct answer: A
Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.
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