HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. The UAP reports to the nurse that a client refused to bathe for the third consecutive day. Which action is best for the nurse to take?
- A. Explain the importance of good hygiene to the client
- B. Ask family members to encourage the client to bathe
- C. Reschedule the bath for the following day
- D. Ask the client why the bath was refused
Correct answer: D
Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reason for refusal is crucial in identifying and addressing any underlying concerns or issues that may be contributing to the refusal. This approach promotes open communication, client-centered care, and helps in developing a plan of care that is tailored to the client's needs and preferences. Choices A, B, and C do not directly address the root cause of the refusal and may not effectively resolve the situation.
2. A client who had a right total shoulder replacement is being prepared for discharge. What should the nurse emphasize to the client to prevent complications?
- A. Avoid lifting objects with the right arm until cleared by the surgeon.
- B. Perform shoulder exercises to regain strength.
- C. Use a sling at all times, even during sleep.
- D. Apply heat to the shoulder to reduce stiffness.
Correct answer: A
Rationale: The correct answer is to avoid lifting objects with the right arm until cleared by the surgeon. After a total shoulder replacement, it is essential to protect the new joint to prevent dislocation or injury. Lifting heavy objects prematurely can lead to complications. While performing shoulder exercises is important for strength, they should be done as per the healthcare provider's instructions to avoid strain on the new joint. Using a sling at all times, as in choice C, is not necessary once the client has regained enough strength and mobility. Applying heat, as in choice D, may not be recommended post-surgery; cold therapy is often preferred to reduce swelling and pain.
3. The practical nurse is caring for a client whose urine drug screen is positive for cocaine. Which behavior is this client likely to exhibit during cocaine withdrawal?
- A. Elevated energy level
- B. Euphoria
- C. High self-esteem
- D. Powerful craving for more
Correct answer: D
Rationale: The correct answer is D: Powerful craving for more. During cocaine withdrawal, individuals often experience intense cravings for the drug, along with symptoms such as fatigue, depression, and anxiety. These cravings can be overpowering and lead to a strong desire to seek out more cocaine to alleviate the withdrawal symptoms. Choices A, B, and C are incorrect as elevated energy level, euphoria, and high self-esteem are more associated with the effects of cocaine rather than withdrawal symptoms. Withdrawal from cocaine is characterized by the opposite, such as fatigue, low mood, and intense cravings.
4. At the first dressing change, the PN tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?
- A. You will feel better when you see that the incision is not as bad as you may think.
- B. It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.
- C. Part of recovery is accepting your new body image, and you will need to look at your incision.
- D. Would you like me to call another nurse to be here while I show you the wound?
Correct answer: B
Rationale: Acknowledging the client's feelings and providing emotional support without pressuring them to look at the incision is important. Choice B is the best response as it respects the client's emotional readiness to confront their body image changes. The client's autonomy and emotional needs are prioritized in this response. Choice A may invalidate the client's feelings by assuming the incision is not as bad as they think, potentially dismissing their emotions. Choice C is insensitive as it imposes a particular view of recovery on the client, disregarding their current emotional state. Choice D may escalate the situation by suggesting the need for another nurse, which could make the client feel uncomfortable and pressured.
5. A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?
- A. Report the finding to the healthcare provider
- B. Place a clear occlusive dressing over the site
- C. Apply a warm compress to remove the crusted area
- D. Explain that this is a normal skin change with aging
Correct answer: A
Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.
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