HESI LPN
HESI PN Exit Exam
1. What intervention should the PN implement when taking the rectal temperature of an adult client?
- A. Lubricate the tip of the thermometer with a water-based gel.
- B. Gently insert the thermometer 1 inch into the rectum.
- C. Hold the thermometer in place the entire time while taking the temperature.
- D. Place the client in the left lateral position.
Correct answer: C
Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.
2. A client recovering from abdominal surgery is on a clear liquid diet. The nurse should identify which of the following as the most appropriate food choice for this diet?
- A. Chicken noodle soup
- B. Grape juice
- C. Cream of wheat
- D. Vanilla pudding
Correct answer: B
Rationale: Grape juice is the most appropriate choice for a clear liquid diet as it is a transparent fluid that is easily digested. Clear liquid diets aim to provide fluids and electrolytes while being easy on the digestive system. Choices A, C, and D are not suitable for a clear liquid diet as they are not in liquid form or do not meet the criteria of being easily digestible for someone recovering from abdominal surgery. Chicken noodle soup, cream of wheat, and vanilla pudding are not considered clear liquids and may not be well-tolerated by a client who has undergone abdominal surgery.
3. A client with hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?
- A. Fresh fruits
- B. Grilled chicken
- C. Whole grain bread
- D. Canned soup
Correct answer: D
Rationale: The correct answer is D, canned soup. Canned soup is often high in sodium, which contradicts the low-sodium diet prescribed for hypertension. Fresh fruits (A) are generally low in sodium and are a healthy choice. Grilled chicken (B) is a lean protein option that is suitable for a low-sodium diet. Whole grain bread (C) is also a good choice as it is not typically high in sodium. Therefore, the LPN/LVN should recommend avoiding canned soup to adhere to the low-sodium dietary restrictions.
4. An angry client screams at the emergency department triage nurse, “I’ve been waiting here for two hours! You and the staff are incompetent”. What is the best response for the nurse to make?
- A. The emergency department is very busy at this time.
- B. I’ll let you see the doctor next because you’ve waited so long.
- C. I’m doing the best I can for the sickest clients first.
- D. I understand you are frustrated with the wait time.
Correct answer: D
Rationale: Correct Answer: The best response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response demonstrates empathy and validates the client's feelings, helping to defuse the situation. Choice A is not the best response as it does not directly address the client's emotions or concerns. Choice B is inappropriate as it gives preferential treatment based on the client's behavior. Choice C, while true, does not acknowledge the client's frustration or offer empathy.
5. A client with a history of atrial fibrillation is prescribed amiodarone. The nurse should monitor for which potential side effect?
- A. Pulmonary toxicity
- B. Liver toxicity
- C. Thyroid dysfunction
- D. Bradycardia
Correct answer: A
Rationale: Corrected Rationale: Amiodarone is known to cause pulmonary toxicity, which can manifest as respiratory symptoms. Monitoring for signs such as cough, dyspnea, or chest pain is essential to detect this serious side effect early and prevent further complications. Choices B, C, and D are incorrect because while amiodarone can also cause liver toxicity, thyroid dysfunction, and bradycardia, pulmonary toxicity is the most serious side effect that requires immediate attention due to its potential life-threatening consequences.