HESI LPN
HESI PN Exit Exam 2024
1. When administering parenteral iron, which action would be inconsistent with proper administration?
- A. Using the Z-track method
- B. Using an air bubble to avoid withdrawing medication into subcutaneous tissue
- C. Not massaging the injection site
- D. Using the deltoid muscle for administration
Correct answer: D
Rationale: The correct answer is D: Using the deltoid muscle for administration. Administering parenteral iron in the deltoid muscle is not recommended due to the risk of irritation and pain. The Z-track method (choice A) is preferred to prevent staining and irritation of the skin when administering irritating medications like iron. Using an air bubble (choice B) to avoid withdrawing medication into subcutaneous tissue is a common practice to ensure accurate administration. Not massaging the injection site (choice C) is also a standard practice to prevent potential irritation or bleeding at the injection site.
2. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?
- A. Apply heat to the residual limb.
- B. Administer prescribed analgesics.
- C. Elevate the residual limb.
- D. Perform range-of-motion exercises.
Correct answer: B
Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.
3. The nurse is assisting the recreational director of a long-term care facility in planning outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?
- A. An open-air concert
- B. A tea party in the courtyard
- C. A team ring-toss competition
- D. A picnic in the park
Correct answer: B
Rationale: A tea party in the courtyard provides a social and physical activity suitable for wheelchair-bound older residents who are mentally alert. It offers an opportunity for social interaction, enjoyment of the outdoors, and participation in a physical activity without the need for extensive mobility. An open-air concert may not provide the same level of social interaction or physical engagement as a tea party. A team ring-toss competition may be physically challenging for wheelchair-bound residents. A picnic in the park could present challenges related to accessibility and might not foster the same level of social interaction as a tea party in a more contained courtyard setting.
4. The PN assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the PN provide the UAP?
- A. Assist the client with a hot bath
- B. Encourage self-care but allow rest periods
- C. Face the client directly when speaking
- D. Keep the head of the bed elevated at all times
Correct answer: B
Rationale: During an acute exacerbation of multiple sclerosis, it is important to encourage self-care to maintain the client's independence. Allowing rest periods helps prevent fatigue, which is crucial in managing MS exacerbations. Choice A is incorrect as hot baths can exacerbate symptoms in MS. Choice C is about communication techniques and not directly related to client care during an exacerbation. Choice D is not a priority intervention during an MS exacerbation.
5. After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?
- A. Remove the air from the solution bag
- B. Obtain a piston syringe and irrigation set
- C. Record the solution added as fluid intake
- D. Calculate the rate of flow of the solution
Correct answer: B
Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.
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