HESI LPN
HESI PN Exit Exam
1. A client is recovering from abdominal surgery and has a nasogastric (NG) tube in place. The nurse notes that the client is experiencing nausea despite the NG tube being patent. What is the nurse's best action?
- A. Increase the suction on the NG tube.
- B. Administer an antiemetic as prescribed.
- C. Irrigate the NG tube with saline.
- D. Reposition the client to the left side.
Correct answer: B
Rationale: Administering an antiemetic as prescribed is the best action for the nurse to take when a client with a patent NG tube is experiencing nausea. This intervention can help relieve nausea effectively. Increasing suction on the NG tube (Choice A) may not address the underlying cause of the nausea and could potentially lead to complications. Irrigating the NG tube with saline (Choice C) is not indicated for addressing nausea in this scenario. Repositioning the client to the left side (Choice D) is not the priority intervention for nausea in a client with a patent NG tube.
2. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)
- A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)
- B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
- D. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative
Correct answer: B
Rationale: The correct answer is B. Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a task within the scope of practice for a practical nurse (PN) and contributes to the client's recovery. Administering insulin (Choice A) involves medication administration, which typically requires a higher level of nursing education. Performing daily surgical dressing changes (Choice C) after an abdominal hysterectomy involves wound care management that is usually beyond the scope of practice for a PN. Initiating patient-controlled analgesia pumps (Choice D) is a complex nursing intervention that requires specialized training and knowledge, exceeding the typical responsibilities of a PN.
3. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
- A. 2 cups of soup
- B. 1 quart of water
- C. 8 oz of ice chips
- D. 6 oz of tea
Correct answer: C
Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.
4. The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?
- A. Aspirates the newborn’s nares using a syringe
- B. Applies a dressing to the cord after the newborn’s bath
- C. Breastfeeds the infant every hour during the night
- D. Positions the infant supine in the crib to sleep
Correct answer: D
Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn’s nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.
5. What is the main function of proteins in the body?
- A. They provide structural components for the body.
- B. They assist in the absorption of vitamins.
- C. They help with the transport of nutrients in the blood.
- D. They help maintain fluid balance in the body.
Correct answer: A
Rationale: The main function of proteins in the body is to provide structural components like muscles, skin, and bones. Proteins are essential for growth, repair, and maintenance of body tissues. While proteins play a role in various physiological functions, their primary function is not to assist in the absorption of vitamins (Choice B), help with the transport of nutrients in the blood (Choice C), or maintain fluid balance (Choice D).