HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the nurse 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. Monitoring blood pressure frequently is crucial in managing glomerulonephritis, as hypertension is a common complication during the acute edematous phase. Choice A is incorrect as it does not address the specific needs of a child with glomerulonephritis. Choice B is incorrect as excessive activity may not be suitable during the acute phase, as rest and monitoring are more important. Choice D is incorrect as the focus should be on monitoring vital signs rather than meal options.
2. Which client should the nurse assess frequently because of the risk for overflow incontinence?
- A. A client who is bedfast, with increased serum BUN and creatinine levels
- B. A client with hematuria and decreasing hemoglobin and hematocrit levels
- C. A client who has a history of frequent urinary tract infections
- D. A client who is confused and frequently forgets to go to the bathroom
Correct answer: A
Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.
3. Monozygotic (MZ) twins are known as fraternal twins.
- A. TRUE
- B. FALSE
- C. Possibly
- D. Never
Correct answer: B
Rationale: The correct answer is B: 'FALSE.' Monozygotic (MZ) twins are identical twins, not fraternal. Fraternal twins are dizygotic (DZ). The statement in the question is incorrect as MZ twins are genetically identical, while fraternal twins actually refer to dizygotic twins who develop from two separate fertilized eggs. Therefore, monozygotic twins are not known as fraternal twins, making option B the correct choice. Options A, C, and D are incorrect as they do not accurately describe the relationship between monozygotic and fraternal twins.
4. James is an 18-month-old child who has had a cough for 7 days with no general danger signs, a temperature of 37.5°C, and a respiratory rate of 41 breaths per minute. How will you classify James' breathing?
- A. Slow breathing
- B. Fast breathing
- C. Normal breathing
- D. Very fast breathing
Correct answer: C
Rationale: The correct answer is 'Normal breathing.' A respiratory rate of 41 breaths per minute is considered normal for an 18-month-old child. Choices A, B, and D are incorrect because a respiratory rate of 41 breaths per minute falls within the normal range for a child of James' age and does not indicate slow, fast, or very fast breathing.
5. In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
- A. Increased edema and weight gain
- B. Unchanged urine specific gravity
- C. Rapid protein excretion
- D. Decreased blood potassium
Correct answer: B
Rationale: After a water deprivation test in a client suspected of having diabetes insipidus, the nurse would expect the urine specific gravity to remain unchanged. This occurs because in diabetes insipidus, the kidneys are unable to concentrate urine, leading to a low urine specific gravity even after water deprivation. Choices A, C, and D are incorrect. Increased edema and weight gain are not typical findings in diabetes insipidus. Rapid protein excretion is not directly related to the condition, and decreased blood potassium is not a common outcome of a water deprivation test for diabetes insipidus.