HESI LPN
HESI PN Exit Exam 2024
1. A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?
- A. The client's bowel sounds.
- B. The client's fluid intake.
- C. The client's pain level.
- D. The client's surgical incision.
Correct answer: A
Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.
2. The practical nurse administered carbidopa-levodopa to a client diagnosed with Parkinson's disease. Which outcome by the client would indicate a therapeutic response?
- A. Decreased blood pressure
- B. Lessening of tremors
- C. Increased salivation
- D. Increased attention span
Correct answer: B
Rationale: The correct answer is B: Lessening of tremors. Carbidopa-levodopa increases the amount of levodopa to the CNS, providing more dopamine to the brain. Increased dopamine levels help alleviate Parkinson's symptoms such as tremors, involuntary movements, and gait abnormalities. Choices A, C, and D are incorrect as carbidopa-levodopa is not expected to have a direct effect on blood pressure, salivation, or attention span in the context of treating Parkinson's disease.
3. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?
- A. Review the fetal heart rate and contraction pattern
- B. Check the perineum for an increase in bloody show
- C. Request a nurse to check the client's cervical dilation
- D. Palpate the client's bladder for distention
Correct answer: C
Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.
4. When discussing hypothyroidism and treatment with the family of a newborn, the nurse should emphasize
- A. Expecting mental retardation in the child is likely
- B. Administering thyroid hormone can prevent problems
- C. This rare problem is always hereditary
- D. Physical growth/development will be delayed
Correct answer: B
Rationale: The correct answer is B. Administering thyroid hormone to a newborn diagnosed with hypothyroidism can prevent developmental delays and mental retardation. This treatment is crucial to ensure optimal growth and development. Choice A is incorrect because with prompt treatment, mental retardation can be prevented. Choice C is incorrect as hypothyroidism can also be acquired and not only hereditary. Choice D is incorrect as physical growth and development can be supported through timely administration of thyroid hormone.
5. An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi’s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take?
- A. Obtain a blood sample to determine if the client is HIV positive
- B. Send the family to the waiting area while conducting a head-to-toe assessment
- C. Complete a head-to-toe assessment to identify other signs of HIV
- D. Ask the family members to wear gloves when touching the client
Correct answer: C
Rationale: In this scenario, the most appropriate action for the nurse to take is to complete a head-to-toe assessment to identify other signs of HIV. Kaposi’s Sarcoma is commonly associated with HIV infection, and conducting a comprehensive assessment can provide crucial information on potential signs and symptoms related to HIV. This information is essential for providing appropriate care and treatment. Option A is not the priority at this moment, as the focus should be on assessing the client comprehensively first. Sending the family members away (Option B) may not be necessary if they are not interfering with the assessment process. While infection control is important, asking the family members to wear gloves (Option D) is not the most critical action to take in this situation.