HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. The nurse and UAP enter a client's room and find the client lying on the bed. The nurse determines that the client is unresponsive. Which instruction should the nurse give the UAP first?
- A. Obtain emergency help
- B. Feel for a carotid pulse
- C. Bring a glucometer to the room
- D. Check the blood pressure
Correct answer: A
Rationale: The correct answer is to instruct the UAP to obtain emergency help first. In a situation where a client is unresponsive, the priority is to ensure that help is summoned promptly. This allows for the availability of necessary resources and assistance for resuscitation or other emergency interventions. Feeling for a carotid pulse or checking the blood pressure can be important assessments but are secondary to obtaining immediate help. Bringing a glucometer to the room, while relevant in certain situations, is not the priority when the client's unresponsiveness indicates a need for urgent intervention.
2. After abdominal surgery, a client has not urinated since the urinary catheter was removed 8 hours ago. What action should the LPN take first?
- A. Perform a bladder scan to assess for urinary retention.
- B. Encourage the client to drink fluids.
- C. Insert a straight catheter to drain the bladder.
- D. Administer a diuretic as prescribed.
Correct answer: A
Rationale: Performing a bladder scan is the initial step to assess for urinary retention in a postoperative client. This non-invasive technique helps determine the volume of urine in the bladder, guiding further interventions. Encouraging the client to drink fluids (Choice B) may be beneficial but is not the priority when assessing for urinary retention. Inserting a straight catheter (Choice C) should not be the initial action without first assessing for retention. Administering a diuretic (Choice D) should not be done without confirming the need through assessment.
3. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?
- A. Lock the wheels on the bed and gurney
- B. Adjust the bed height
- C. Use a slide sheet
- D. Ask for assistance from another nurse
Correct answer: A
Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.
4. The nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, 'Get out of here! I'll get up when I'm ready!' Which response is best for the nurse to make?
- A. Your healthcare provider has prescribed ambulation on the first postoperative day.
- B. You must ambulate to avoid complications that could cause more discomfort than ambulating.
- C. I know how you feel. You're angry about having to ambulate, but this will help you get well.
- D. I'll be back in 30 minutes to help you get out of bed and walk around the room.
Correct answer: D
Rationale: (D) provides a 'cooling off' period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with an intellectually disabled client and is threatening the client with 'complications.' (C) is telling the client how she feels (angry), and the nurse does not really 'know' how this client feels, unless the nurse is also intellectually disabled and has also just had an appendectomy.
5. On the third day of hospitalization, the nurse observes that a 2-year-old toddler who had been screaming and crying inconsolably begins to regress and is now lying quietly in the crib with a blanket. What stage of separation anxiety has developed?
- A. Denial
- B. Despair
- C. Mistrust
- D. Rejection
Correct answer: B
Rationale: The correct answer is B: 'Despair'. In separation anxiety, the stage of despair is characterized by regression and withdrawal after the initial protest. The toddler's shift from intense crying to lying quietly with a blanket demonstrates this withdrawal behavior. Choice A, 'Denial', is incorrect as denial involves refusing to accept the reality of separation. Choice C, 'Mistrust', is incorrect as it relates to a lack of trust rather than the stage of separation anxiety described in the scenario. Choice D, 'Rejection', is incorrect as it does not reflect the behavior of the toddler in the scenario, which is more indicative of withdrawal and regression.