HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. Which task could the nurse safely delegate to the UAP?
- A. Oral feeding of a two-year-old child after application of a hip spica cast
- B. Assessment of the placement and patency of an NG tube
- C. Participation in staff rounds to record notes regarding client goals
- D. Evaluation of a client's incisional pain following narcotic administration
Correct answer: A
Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.
2. A client post-mastectomy is concerned about the risk of lymphedema. What should the nurse include in the discharge instructions to minimize this risk?
- A. Wear compression garments on the affected arm.
- B. Avoid venipunctures and blood pressure measurements on the affected arm.
- C. Perform vigorous exercises to strengthen the affected arm.
- D. Keep the affected arm elevated at all times.
Correct answer: B
Rationale: To minimize the risk of lymphedema after a mastectomy, it is essential to instruct the client to avoid venipunctures and blood pressure measurements on the affected arm. These procedures can lead to trauma or impede lymphatic flow, increasing the risk of lymphedema. Wearing compression garments helps manage lymphedema but is not preventive. Performing vigorous exercises can strain the affected arm and increase the risk of lymphedema. Keeping the affected arm elevated at all times is unnecessary and not an effective preventive measure against lymphedema.
3. 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.
4. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?
- A. Using a sterile technique
- B. Ensuring correct placement of the CVC
- C. Flushing the CVC with saline after administration
- D. Monitoring for signs of infection
Correct answer: B
Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.
5. What should the nurse do to complete a focused assessment for a female client with inflamed and painful hemorrhoids?
- A. Determine if the client uses any over-the-counter preparations for hemorrhoids
- B. Place the client in a standing position, leaning over the exam bed for inspection
- C. Position the client in the left lateral position to inspect the perineal area for fissures or sacs
- D. Ask the client how long she has experienced discomfort related to hemorrhoids
Correct answer: D
Rationale: Asking the client about the duration of discomfort related to hemorrhoids is the best intervention to implement for a focused assessment. This information provides important context for assessing the severity and chronicity of the condition, which is crucial for developing an appropriate care plan. Choices A, B, and C do not directly address the need to gather information about the duration of symptoms, which is essential for understanding the client's condition.
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