HESI LPN
HESI PN Exit Exam 2023
1. Which electrolyte imbalance is most commonly associated with seizures?
- A. Hyponatremia
- B. Hypercalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct answer: A
Rationale: The correct answer is A: Hyponatremia. Hyponatremia, characterized by low sodium levels in the blood, can lead to cerebral edema and seizures due to water shifting into brain cells. Hypercalcemia (choice B) does not commonly cause seizures but can result in muscle weakness and cardiac arrhythmias. Hyperkalemia (choice C) may lead to muscle weakness and cardiac arrhythmias, but it is less frequently associated with seizures. Hypokalemia (choice D) is linked to muscle weakness and cardiac arrhythmias but is not typically related to seizures.
2. A young adult male is admitted to the intensive care unit with multiple rib fractures and severe pulmonary contusions after falling 20 feet from a rooftop. The Chest X-ray suggests acute Respiratory distress Syndrome. Which assessment finding warrants immediate intervention by the Nurse?
- A. Apical pulse 58 bpm.
- B. Core body temperature 100.8°F.
- C. Tachypnea with dyspnea.
- D. Multiple bruises over the chest area.
Correct answer: C
Rationale: In a patient with multiple rib fractures, severe pulmonary contusions, and possible acute Respiratory Distress Syndrome (ARDS), tachypnea (rapid breathing) with dyspnea (shortness of breath) is a critical sign of respiratory distress that warrants immediate intervention by the nurse. Tachypnea and dyspnea indicate inadequate oxygenation and ventilation, which can lead to respiratory failure if not addressed promptly. The other options, such as apical pulse rate, core body temperature, and bruises over the chest area, are important assessments but do not directly indicate the immediate need for intervention in a patient with respiratory distress.
3. A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?
- A. “I will place the client on their side.”
- B. “I will go to the nurses’ station for assistance.”
- C. “I will note the time that the seizure begins.”
- D. “I will prepare to insert an airway.”
Correct answer: B
Rationale: The correct answer is B. Going to the nurses’ station for assistance during a seizure is inappropriate as immediate care is necessary. Placing the client on their side helps maintain an open airway and prevents aspiration. Noting the time the seizure begins is crucial for monitoring and documentation. Preparing to insert an airway may be necessary if the client's airway becomes compromised. Therefore, the nurse's statement about going to the nurses' station for assistance is the only incorrect response as it delays essential care.
4. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct answer: C
Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.
5. The mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex is being taught by the nurse. Which response from his mother indicates a need for further teaching?
- A. He needs to wear a medical alert identification.
- B. I will need to inform his caregivers about this.
- C. A product's label always indicates if it is latex-free.
- D. He should avoid all contact with latex.
Correct answer: C
Rationale: Choice C indicates a need for further teaching because not all products are clearly labeled as latex-free. It is essential for the mother to understand that she should not solely rely on product labels to determine latex content. She should be encouraged to verify with manufacturers and consult healthcare providers for accurate information. Choices A, B, and D are correct responses. Wearing a medical alert identification, informing caregivers, and ensuring the boy avoids all contact with latex are crucial steps in managing his sensitivity to latex and preventing potential allergic reactions.