HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?
- A. Protect the client's feet from injury
- B. Apply a heating pad to the affected area
- C. Keep the client's feet elevated
- D. Assess the feet and legs for jaundice
Correct answer: A
Rationale: Protecting the client's feet from injury is critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.
2. An unlicensed assistive personnel (UAP) places a client in a left lateral position before administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in a Sim's position with the weight on the anterior ilium.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct answer: C
Rationale: The correct instruction the LPN/LVN should provide to the UAP is to reposition the client in a Sim's position with the weight on the anterior ilium for administering a soap suds enema. This position helps facilitate the administration of the enema by providing better access and comfort for the client. Choice A is incorrect as reverse Trendelenburg is not the appropriate position for administering a soap suds enema. Choice B is incorrect as the concentration of soap in the enema solution is not specified and might be too strong. Choice D is incorrect as raising the side rails and elevating the bed does not directly relate to the proper positioning for administering the enema.
3. A client with diabetes mellitus is being taught by a nurse how to perform a capillary blood glucose test. Which of the following instructions should the nurse include in the teaching?
- A. Don sterile gloves after cleansing the site
- B. Puncture the site after cleansing and before the antiseptic dries
- C. Gently wipe the puncture site until a large droplet of blood forms
- D. Hold the finger below the heart level to puncture
Correct answer: B
Rationale: The correct instruction is to puncture the site after cleansing and before the antiseptic dries. This sequence helps ensure proper blood collection without introducing contaminants. Choice A is incorrect because wearing sterile gloves is not necessary for capillary blood glucose testing. Choice C is incorrect as wiping the puncture site can introduce contaminants and alter the blood sample. Choice D is incorrect as holding the finger below the heart level is not required for a capillary blood glucose test.
4. The school RN is assessing a group of middle school students for signs of scoliosis and discovers a female student with noticeable unequal symmetry of the upper and lower back. Which intervention is most important for the RN to implement?
- A. Send the student home
- B. Make a referral to have the scoliosis further evaluated.
- C. Withdraw the student from all physical activities
- D. Tell the student not to carry her backpack on her back
Correct answer: B
Rationale: Referring the student for further evaluation of scoliosis is crucial to confirm the diagnosis and determine the appropriate management plan. Sending the student home (choice A) without proper assessment and intervention is not the best course of action. Withdrawing the student from all physical activities (choice C) is not necessary and may cause unnecessary distress. Instructing the student not to carry her backpack on her back (choice D) does not address the underlying issue of scoliosis and is not the most important intervention at this point.
5. When caring for a child diagnosed with bronchiolitis, what is the priority nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct answer: B
Rationale: The priority nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention aims to maintain airway patency, optimize oxygenation, and support effective breathing. Administering bronchodilators, though important, may not be the initial priority as respiratory therapy takes precedence in ensuring adequate oxygenation and ventilation. Monitoring oxygen saturation is crucial but is usually part of the ongoing assessment following the initiation of respiratory therapy. Encouraging fluid intake is essential for hydration but is not the priority intervention when addressing the respiratory distress associated with bronchiolitis.