HESI LPN
HESI PN Exit Exam 2024
1. 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.
2. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?
- A. Recommend parents bring favorite snacks
- B. Encourage ambulation daily to the playroom
- C. Measure blood pressure every 4 to 6 hours
- D. Offer a selection of fresh fruit for each meal
Correct answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.
3. 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.
4. The HCP gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her that she needs to increase foods in her diet because her hemoglobin is 8.2 grams/dL. When a list of iron-rich foods is given to the client, she tells the PN that she is a vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide?
- A. All below
- B. Increase green leafy vegetables in the diet
- C. Oatmeal is a good choice for breakfast
- D. Add lentils and black beans to soup
Correct answer: A
Rationale: Vegetarians can increase their iron intake through plant-based sources such as green leafy vegetables, oatmeal, and legumes, which are rich in iron.
5. What is the primary cause of diabetic ketoacidosis (DKA)?
- A. Insulin deficiency
- B. Overhydration
- C. Excess carbohydrate intake
- D. Excess insulin
Correct answer: A
Rationale: The correct answer is A: Insulin deficiency. Diabetic ketoacidosis occurs due to a severe lack of insulin, causing the body to break down fat for energy, leading to the production of ketones and acidification of the blood. Option B, Overhydration, is incorrect as DKA is characterized by dehydration rather than overhydration. Option C, Excess carbohydrate intake, is incorrect because while high blood sugar levels can contribute to DKA, the primary cause is insulin deficiency. Option D, Excess insulin, is also incorrect as DKA is not caused by an excess of insulin but rather by a lack of it.
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