HESI LPN
HESI PN Exit Exam 2023
1. A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
- A. Take all prescribed antibiotics as directed.
- B. Avoid crowded places and people who are sick.
- C. Wash hands frequently and practice good hygiene.
- D. Keep the surgical site clean and dry.
Correct answer: C
Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.
2. The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right. She tells the nurse, "Now my daughter is not getting enough to eat." Which response would be best for the nurse to make?
- A. Feed your baby hourly until you feel confident that your child is receiving enough milk.
- B. Don't worry, soon your milk will come in, and you will feel how full your breasts are.
- C. Since you are so concerned, you should probably supplement breastfeeding with formula.
- D. If your baby's urine is straw-colored, she's getting enough milk.
Correct answer: D
Rationale: Reassuring the mother that the baby's urine color can be an indicator of adequate hydration can help her feel more confident in her breastfeeding.
3. Prior to a client being transported for a chest x-ray, what should a healthcare professional do first?
- A. Identify the client using two identifiers
- B. Confirm the client's fasting status
- C. Check the client's allergies to contrast media
- D. Explain the procedure to the client
Correct answer: A
Rationale: Identifying the client using two identifiers is the crucial first step to ensure correct patient identification before any procedure. This process helps prevent errors and ensures that the right procedure is performed on the right patient. Confirming the client's identity is the top priority before addressing other aspects such as fasting status, allergies, or explaining the procedure. While confirming fasting status and checking for allergies are important, they are secondary to confirming the client's identity. Explaining the procedure to the client is also essential but should occur after ensuring proper identification.
4. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
- A. "I'm having mild pain."
- B. "The pain is like a dull ache in my stomach."
- C. "I notice that the pain gets worse after I eat."
- D. "The pain makes me feel nauseous."
Correct answer: B
Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.
5. In planning care for a postoperative client with hypovolemic shock, which problem is most important to include in the plan of care?
- A. Risk for infection.
- B. Risk for falls.
- C. Impaired skin integrity.
- D. Activity intolerance.
Correct answer: B
Rationale: The correct answer is B: Risk for falls. In a postoperative client with hypovolemic shock, the most crucial problem to address is the risk for falls. Hypovolemic shock can result in dizziness and weakness, making the client prone to falling. Preventing falls is essential to avoid further injury or complications. Choices A, C, and D are not the top priority in this scenario. While infection, impaired skin integrity, and activity intolerance are important concerns, preventing falls takes precedence due to the immediate risk of injury associated with hypovolemic shock.