HESI LPN
HESI PN Exit Exam 2023
1. The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement?
- A. Obtain further data about the client's activity intolerance to position changes
- B. Advise the UAP to allow the client to rest before completing the bath
- C. Direct the UAP to obtain vital signs and a pulse oximetry reading
- D. Notify the healthcare provider about the client's episode of SOB
Correct answer: B
Rationale: Advising the UAP to allow the client to rest before completing the bath is the most appropriate action to take. This helps manage the shortness of breath (SOB) experienced by the client and prevents further stress. By giving the client time to rest, the PN ensures the client's comfort and safety during care activities. The other options are not the most immediate or appropriate actions in this scenario: obtaining further data about activity intolerance (choice A) may delay addressing the current issue, obtaining vital signs and pulse oximetry (choice C) is important but not as immediate as allowing the client to rest, and notifying the healthcare provider (choice D) is premature before trying a simple intervention like allowing the client to rest.
2. A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?
- A. Massage the calf and foot
- B. Elevate the leg above the heart
- C. Check the pedal pulse in the affected leg
- D. Extend the leg and flex the foot
Correct answer: D
Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.
3. Which neurotransmitter is most closely associated with mood regulation and is targeted by antidepressants?
- A. Serotonin
- B. Dopamine
- C. GABA
- D. Acetylcholine
Correct answer: A
Rationale: The correct answer is A: Serotonin. Serotonin plays a vital role in mood regulation, and its imbalance is often associated with depression. Many antidepressants function by boosting serotonin levels in the brain. Dopamine (Choice B) is more linked to reward and pleasure pathways in the brain, not primarily targeted for mood regulation. GABA (Choice C) is an inhibitory neurotransmitter that helps reduce neuronal excitability, not primarily associated with mood regulation. Acetylcholine (Choice D) is involved in muscle movement and cognitive functions, not the primary target of antidepressants for mood regulation.
4. What is the correct order of steps in the nursing process?
- A. Assessment, Diagnosis, Planning, Implementation, Evaluation
- B. Planning, Implementation, Evaluation, Diagnosis, Assessment
- C. Diagnosis, Assessment, Planning, Implementation, Evaluation
- D. Implementation, Planning, Evaluation, Diagnosis, Assessment
Correct answer: A
Rationale: The correct order in the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment involves gathering information about the patient, Diagnosis is identifying the problem, Planning involves setting goals and outcomes, Implementation is carrying out the plan, and Evaluation is assessing the outcomes. Choices B, C, and D have the steps in the incorrect order, not following the standard nursing process framework. Therefore, the correct answer is option A.
5. When documenting information in a client's medical record, what should the nurse do?
- A. Cross out errors with a single line and initial them
- B. Use a black ink pen
- C. Leave one line blank before each new entry
- D. End each entry with the nurse's signature and title
Correct answer: D
Rationale: When documenting information in a client's medical record, the nurse should end each entry with their signature and title. This practice is crucial for legal and professional standards compliance as it ensures that the documentation is attributable to the responsible individual. Choices A, B, and C are incorrect because while crossing out errors, using a black ink pen, and leaving a blank line before each entry are good practices, they are not as critical as ensuring each entry is signed and titled by the nurse for accountability and traceability.
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