HESI LPN
HESI PN Exit Exam 2024
1. When caring for a patient with a chest tube, which nursing action is most important?
- A. Clamping the chest tube every 2 hours to prevent air leaks
- B. Keeping the drainage system below chest level
- C. Emptying the drainage system every hour to prevent backflow
- D. Removing the chest tube when drainage decreases significantly
Correct answer: B
Rationale: The most crucial nursing action when caring for a patient with a chest tube is to keep the drainage system below chest level (choice B). This position helps ensure proper drainage and prevents backflow of fluid or air into the pleural space, promoting optimal functioning of the chest tube. Clamping the chest tube every 2 hours (choice A) is incorrect as it can obstruct the drainage system and lead to complications. Emptying the drainage system every hour (choice C) is unnecessary unless there are specific clinical indications. Removing the chest tube when drainage decreases significantly (choice D) is also incorrect as the decision should be based on overall clinical assessment rather than drainage amount alone.
2. What is the most common genetic cause of intellectual disability?
- A. Down syndrome
- B. Fragile X syndrome
- C. Prader-Willi syndrome
- D. Turner syndrome
Correct answer: B
Rationale: The correct answer is Fragile X syndrome because it is the most common inherited cause of intellectual disability, resulting from a mutation in the FMR1 gene. Down syndrome, Prader-Willi syndrome, and Turner syndrome are not the most common genetic causes of intellectual disability. Down syndrome is caused by the presence of an extra chromosome 21, Prader-Willi syndrome results from specific genetic abnormalities on chromosome 15, and Turner syndrome is characterized by the absence of part or all of one of the X chromosomes.
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. 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.
5. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?
- A. Review the fetal heart rate and contraction pattern
- B. Check the perineum for an increase in bloody show
- C. Request a nurse to check the client's cervical dilation
- D. Palpate the client's bladder for distention
Correct answer: C
Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.
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