HESI LPN
HESI PN Exit Exam
1. When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?
- A. In front of the body to lean on while stepping forward
- B. On the opposite side of the affected extremity
- C. Approximately one foot away from the body to stabilize balance
- D. On the same side as the affected extremity
Correct answer: B
Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.
2. Which of the following dietary modifications should be recommended for a patient with chronic kidney disease (CKD)?
- A. High protein, low sodium
- B. Low protein, high potassium
- C. Low sodium, low potassium
- D. High calcium, low phosphorus
Correct answer: C
Rationale: A low sodium, low potassium diet is often recommended for patients with CKD to manage fluid balance and prevent electrolyte imbalances that the kidneys can no longer regulate effectively. High protein diets, as mentioned in choice A, can put extra strain on the kidneys, making it an incorrect choice. Choice B, which suggests a low protein, high potassium diet, is also incorrect because high potassium levels can be harmful to individuals with CKD. Choice D, advocating for a high calcium, low phosphorus diet, is not the typical dietary recommendation for CKD patients, even though managing calcium and phosphorus levels is important in their diet.
3. Which electrolyte imbalance is most likely to cause cardiac arrhythmias?
- A. Hyperkalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hypokalemia
Correct answer: A
Rationale: Hyperkalemia is the correct answer as it can lead to dangerous cardiac arrhythmias due to its effects on the electrical conduction of the heart. High levels of potassium can disrupt the normal electrical activity of the heart, potentially leading to life-threatening arrhythmias. Hypocalcemia (choice B) is not the most likely cause of cardiac arrhythmias compared to hyperkalemia. Hypernatremia (choice C), referring to high sodium levels, is not directly associated with causing cardiac arrhythmias. While hypokalemia (choice D), low potassium levels, can also lead to cardiac arrhythmias, hyperkalemia is the more likely culprit in causing severe disturbances in heart rhythm.
4. What is the most common cause of acute pancreatitis?
- A. Gallstones
- B. Alcohol abuse
- C. Hypertriglyceridemia
- D. Infection
Correct answer: A
Rationale: The correct answer is A: Gallstones. Gallstones are the most common cause of acute pancreatitis as they obstruct the pancreatic duct, leading to inflammation. While alcohol abuse (Choice B) can also cause pancreatitis, gallstones are more prevalent. Hypertriglyceridemia (Choice C) is a less common cause of acute pancreatitis compared to gallstones. Infection (Choice D) is not a primary cause of acute pancreatitis; gallstones are the leading etiology.
5. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?
- A. Check the placement of the NG tube
- B. Flush the tube with saline
- C. Position the client in a semi-Fowler's position
- D. Administer the medication slowly
Correct answer: A
Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.
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