HESI LPN
HESI PN Exit Exam 2023
1. After admission, which observation is most important for the nurse to report immediately for an adult client who weighs 150 pounds and has partial-thickness and full-thickness burns over 40% of the body from a house fire?
- A. Poor appetite and refusal to eat
- B. Systolic blood pressure at 102
- C. Painful moaning and crying
- D. Urinary output of 20 ml/hr
Correct answer: D
Rationale: A urinary output of 20 ml/hr is a sign of inadequate kidney perfusion and could indicate hypovolemic shock, which requires immediate intervention. In this situation, with severe burns over a large portion of the body, monitoring urinary output is crucial to assess kidney function and fluid status. Poor appetite, systolic blood pressure at 102, and painful moaning and crying are important but do not indicate the immediate need for intervention like inadequate urinary output does.
2. A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). What should the LPN/LVN include in the teaching plan?
- A. Take the medication with food to avoid nausea.
- B. You may start feeling better within 1 to 2 weeks.
- C. The medication may take 4 to 6 weeks to become fully effective.
- D. You may experience side effects such as dry mouth or dizziness.
Correct answer: C
Rationale: Teaching the client that the medication may take 4 to 6 weeks to become fully effective is crucial as it helps set realistic expectations. While choice A is important to reduce nausea, it is not the most critical information to provide initially. Choice B is incorrect as improvement usually occurs after several weeks of treatment, not within 1 to 2 weeks. Choice D is also relevant, but informing about the full effectiveness of the medication is more important for long-term adherence.
3. A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?
- A. Administer a prescribed PRN antiemetic
- B. Assess the client for the presence of hemorrhoids
- C. Check the client’s hemoglobin level
- D. Review the client’s current list of medications
Correct answer: D
Rationale: The correct action for the nurse to implement in a client experiencing clear, watery diarrhea is to review the client's current list of medications. Certain medications can cause diarrhea as a side effect, so identifying any potential culprits is essential. Administering an antiemetic (Choice A) is not appropriate for diarrhea, as antiemetics are used to control nausea and vomiting, not diarrhea. Assessing for hemorrhoids (Choice B) is not the priority when the client is experiencing watery diarrhea; addressing the root cause is crucial. Checking the client’s hemoglobin level (Choice C) is not the immediate action needed for this situation as it does not directly address the cause of diarrhea.
4. When should a nurse on a labor and delivery unit instruct a newly licensed nurse to don gloves for a procedure?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn's initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct answer: B
Rationale: The correct answer is B: Performing a newborn's initial bath. Gloves should be worn during this procedure to protect against exposure to body fluids, such as amniotic fluid or blood. Assisting a mother with breastfeeding (Choice A) does not typically require gloves unless there are specific reasons for infection control. Administering vaccines (Choice C) and performing umbilical cord care (Choice D) are procedures that may require hand hygiene but not necessarily gloves, unless there is active bleeding or potential exposure to body fluids. The initial bath involves direct contact with body fluids, making it crucial to wear gloves for protection.
5. A child is admitted to the hospital with pneumonia. What is the priority need that must be included in the nursing plan of care for this child?
- A. Rest
- B. Exercise
- C. Nutrition
- D. Elimination
Correct answer: A
Rationale: The correct answer is Rest. When a child is admitted to the hospital with pneumonia, the priority need in the nursing plan of care is to ensure adequate rest for the child. Rest is crucial as it allows the child's body to fight the infection and recover. Choice B, Exercise, is incorrect as strenuous physical activity may further strain the child's respiratory system. Choice C, Nutrition, is important but providing rest takes precedence initially. Choice D, Elimination, is not the priority concern in this scenario compared to ensuring rest for recovery from pneumonia.