HESI LPN
HESI PN Exit Exam 2024
1. A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?
- A. Encourage the client to get plenty of exercise in addition to the dietary change
- B. Provide written information about the seven warning signs of cancer
- C. Remind the client to ensure that the dairy products are fortified with Vitamin D
- D. Suggest that an increase in fruits and vegetables is more beneficial
Correct answer: D
Rationale: Increasing fruits and vegetables in the diet is more beneficial in reducing cancer risk due to their high levels of antioxidants and fiber, which help protect against cancer. While exercise is important for overall health, in this context, focusing on fruits and vegetables is more relevant to reducing cancer risk than exercise alone. Providing information about cancer warning signs is not directly addressing the client's dietary choice. While Vitamin D is essential for various health aspects, the primary focus here should be on a diet rich in fruits and vegetables for cancer risk reduction.
2. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?
- A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
- B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
- C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
- D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.
Correct answer: B
Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.
3. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct answer: B
Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient involves physically moving and adjusting their position in bed, which is a task that can be safely delegated to nursing assistive personnel (NAP). This task does not require clinical judgment or assessment skills beyond the ability to follow guidelines for proper positioning. Choices A, C, and D involve assessments or judgments that require a higher level of training and knowledge, making them more appropriate for a nurse to perform. Choice A involves assessing comfort, which may involve subjective factors and individual preferences. Choice C involves identifying hazards related to immobility, which requires understanding the potential risks and complications associated with immobility. Choice D involves assessing circulation, which requires a higher level of clinical knowledge and understanding of circulatory issues.
4. A client is scheduled for a sigmoidoscopy and expresses anxiety about the procedure. What should the nurse do first?
- A. Offer information about the procedure steps
- B. Administer an anxiolytic before the procedure
- C. Encourage the client to discuss their fears
- D. Reassure the client that the procedure is common and safe
Correct answer: C
Rationale: The correct first action for the nurse when a client expresses anxiety about a procedure is to encourage the client to discuss their fears. By allowing the client to express their concerns, the nurse can provide personalized support, address specific worries, and offer tailored information. This approach helps to establish trust, reduce anxiety, and promote a therapeutic nurse-client relationship. Offering information about the procedure steps (Choice A) may be helpful but should come after addressing the client's fears. Administering an anxiolytic (Choice B) should not be the first action as it focuses on symptom management rather than addressing the underlying cause of anxiety. Reassuring the client that the procedure is common and safe (Choice D) is important but should follow active listening and addressing the client's fears.
5. What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?
- A. Assessing the strength of uterine contractions
- B. Re-evaluating the need for medication
- C. Reminding her to push 3 times with each contraction
- D. Assisting her to maintain control
Correct answer: D
Rationale: During the transitional phase of labor, which is the most intense phase, the primary focus of nursing care for a client who anticipates an unmedicated delivery should be assisting her to maintain control. This is essential to help her manage the intense pain and anxiety associated with this phase without the use of medication. Assessing the strength of uterine contractions (Choice A) is important but not the primary focus during the transitional phase. Re-evaluating the need for medication (Choice B) is not applicable as the client anticipates an unmedicated delivery. Reminding her to push 3 times with each contraction (Choice C) is more related to the pushing stage of labor and not the transitional phase.