HESI LPN
HESI PN Exit Exam
1. What is the function of the epiglottis during swallowing?
- A. Prevents food from entering the trachea
- B. Aids in food propulsion
- C. Enhances taste sensation
- D. Lubricates the esophagus
Correct answer: A
Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.
2. At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score?
- A. 4
- B. 6
- C. 8
- D. 10
Correct answer: C
Rationale: The Apgar score is based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a heart rate over 100 (2 points), is crying (2 points indicating good respiratory effort), resists the catheter (2 points for good reflex irritability), but has acrocyanosis (partial point deduction of 1). Thus, the Apgar score at one minute after birth would be 8. Choice A is incorrect as the given signs indicate a higher score. Choice B is incorrect as the signs described support a score above 6. Choice D is incorrect as it represents a perfect score which is not the case here due to acrocyanosis.
3. The nurse is preparing to provide wound care for a client. Which step should be done first?
- A. Don procedural gloves
- B. Remove the dressing
- C. Apply prescribed medications to the wound
- D. Don a pair of sterile gloves
Correct answer: A
Rationale: The correct answer is to don procedural gloves first. Donning procedural gloves is essential to protect the nurse from contaminants while removing the old dressing. This step helps maintain aseptic technique and prevents the transfer of microorganisms. Removing the dressing (choice B) should follow after wearing gloves to prevent the spread of pathogens. Applying prescribed medications (choice C) should be done after the wound is cleaned and dressed. Donning a pair of sterile gloves (choice D) is not necessary for initial wound care; procedural gloves are sufficient for standard wound care.
4. A client who had a thyroidectomy 24 hours ago reports tingling around the mouth and in the fingertips. What should the nurse do first?
- A. Check the client’s calcium levels.
- B. Administer a dose of calcium gluconate.
- C. Assess the client's incision site for bleeding.
- D. Notify the healthcare provider.
Correct answer: A
Rationale: Tingling around the mouth and in the fingertips can indicate hypocalcemia, a potential complication after thyroidectomy due to accidental damage to the parathyroid glands. Checking calcium levels is crucial as it helps in diagnosing hypocalcemia accurately. Administering calcium without knowing the actual calcium levels can be dangerous. Assessing the incision site for bleeding is important but not the priority in this situation. Notifying the healthcare provider can be done after assessing and managing the immediate concern of hypocalcemia.
5. The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN 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. When a client is unresponsive, it could indicate a life-threatening condition that requires immediate intervention. Ensuring emergency help is on the way is the priority to address the potentially critical situation. Feeling for a carotid pulse, bringing a glucometer, or checking the blood pressure are important assessments but should come after taking steps to secure immediate assistance.
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