HESI LPN
HESI PN Exit Exam
1. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?
- A. The client's bladder for distension.
- B. The IV catheter insertion site.
- C. The patency of the urinary catheter.
- D. The client's vital signs.
Correct answer: C
Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.
2. What should be assessed in an infant diagnosed with hypertrophic pyloric stenosis?
- A. Diarrhea after each feeding
- B. Gastric pain and vigorous crying
- C. Poor appetite due to poor sucking reflex
- D. An olive-shaped mass right of the midline
Correct answer: D
Rationale: In hypertrophic pyloric stenosis, an olive-shaped mass can often be palpated in the infant's abdomen, which is a hallmark sign of this condition. This mass is located in the right upper quadrant of the abdomen, right of the midline. Choices A, B, and C are incorrect because while infants with hypertrophic pyloric stenosis may experience vomiting (not diarrhea), gastric pain, and irritability, and have feeding difficulties, the key assessment finding specific to this condition is the palpable olive-shaped mass in the abdomen.
3. A client who is at 24 weeks of gestation is receiving teaching about expected changes during pregnancy. Which of the following information should the nurse include?
- A. Your stomach will empty rapidly
- B. You should expect your uterus to double in size
- C. You should anticipate nasal stuffiness
- D. Your nipples will become lighter in color
Correct answer: C
Rationale: Nasal stuffiness is a common symptom during pregnancy due to increased blood flow and hormonal changes. This symptom is caused by the increased blood volume and hormonal changes that lead to swelling of the nasal passages. Choices A, B, and D are incorrect. Stomach emptying rate does not significantly change during pregnancy; the uterus does not double in size at 24 weeks but rather grows steadily, and nipples typically darken in color due to increased pigmentation.
4. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What is the priority nursing action for the LPN/LVN?
- A. Administer insulin as prescribed.
- B. Administer oral hypoglycemic agents.
- C. Monitor blood glucose levels frequently.
- D. Provide a high-calorie diet.
Correct answer: A
Rationale: The correct answer is to administer insulin as prescribed. When a client with diabetes mellitus presents with a critically high blood glucose level like 600 mg/dL, the priority action is to lower the blood glucose level promptly to prevent complications. Insulin is the appropriate medication to rapidly reduce high blood glucose levels. Administering oral hypoglycemic agents may not act quickly enough in this critical situation. While monitoring blood glucose levels frequently is important, immediate intervention to lower the high blood glucose level takes precedence. Providing a high-calorie diet is contraindicated in this scenario as it would further elevate the blood glucose level.
5. What is the recommended first step in the management of a child with a suspected head injury?
- A. Administer pain medication
- B. Assess the child's level of consciousness
- C. Perform a CT scan
- D. Monitor for seizures
Correct answer: B
Rationale: The correct first step in managing a child with a suspected head injury is to assess the child's level of consciousness. This assessment is crucial as it helps determine the severity of the injury and guides further management. Administering pain medication (Choice A) should not be done before assessing the level of consciousness. Performing a CT scan (Choice C) may be necessary but is not the initial step. Monitoring for seizures (Choice D) is important but comes after assessing the child's level of consciousness.