HESI LPN
HESI PN Exit Exam
1. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?
- A. Due date
- B. Blood pressure
- C. Gravida and parity
- D. Fundal height
Correct answer: B
Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.
2. When caring for a client with borderline personality disorder, what is the most effective nursing intervention?
- A. Set clear and consistent boundaries for the client.
- B. Allow the client to vent their feelings without interruption.
- C. Encourage the client to participate in group therapy.
- D. Provide the client with frequent reassurance and support.
Correct answer: A
Rationale: Setting clear and consistent boundaries is essential when caring for a client with borderline personality disorder. This intervention helps provide structure, maintain a therapeutic relationship, and prevent manipulative behaviors. Allowing the client to vent feelings without interruption (Choice B) may not address the underlying issues effectively. Encouraging participation in group therapy (Choice C) can be beneficial but setting boundaries is more crucial. Providing frequent reassurance and support (Choice D) may inadvertently reinforce maladaptive behaviors instead of promoting growth and independence.
3. A client with diabetes mellitus type 2 is prescribed canagliflozin. The nurse should include which instruction in the client's teaching plan?
- A. Report any signs of urinary tract infection.
- B. Take this medication with meals.
- C. Avoid alcohol while taking this medication.
- D. Avoid taking this medication with grapefruit juice.
Correct answer: A
Rationale: The correct instruction to include in the client's teaching plan is to report any signs of urinary tract infection. Canagliflozin, a medication used in diabetes mellitus type 2, can increase the risk of urinary tract infections. Instructing the client to report any signs of infection is crucial for early intervention and management. Choices B, C, and D are incorrect because there is no specific requirement to take canagliflozin with meals, avoid alcohol, or restrict grapefruit juice consumption while on this medication.
4. The healthcare provider prescribes 10 units per liter of oxytocin via IV drip to augment a client's labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
- A. Contraction duration of 100 seconds.
- B. Four contractions in 10 minutes.
- C. Uterus is soft.
- D. Early deceleration of fetal heart rate.
Correct answer: A
Rationale: A contraction duration of 100 seconds is too long and can indicate uterine hyperstimulation, which can lead to fetal distress and other complications. This prolonged contraction duration suggests that the uterus is not relaxing adequately between contractions, potentially compromising fetal oxygenation. Choice B, 'Four contractions in 10 minutes,' is a sign of tachysystole, which is concerning but not as immediately critical as the prolonged contraction duration. Choice C, 'Uterus is soft,' is not a reason to discontinue oxytocin; in fact, it is a normal finding. Choice D, 'Early deceleration of fetal heart rate,' while indicating fetal distress, is not a direct result of the oxytocin and may require intervention but not immediate discontinuation of the medication.
5. What is a common treatment for a child with moderate to severe eczema?
- A. Topical corticosteroids
- B. Oral antibiotics
- C. Frequent saline irrigation
- D. High-calcium diet
Correct answer: A
Rationale: Topical corticosteroids are the correct answer for a child with moderate to severe eczema. These medications are commonly used to reduce inflammation and itching associated with eczema. Oral antibiotics (Choice B) are not typically used in eczema treatment unless there is a secondary bacterial infection. Frequent saline irrigation (Choice C) may aid in wound care but is not a primary treatment for eczema. A high-calcium diet (Choice D) is not a standard treatment for eczema and does not target the underlying inflammatory process that causes eczema symptoms.