HESI LPN
HESI PN Exit Exam 2024
1. Which nursing intervention is most appropriate for managing delirium in an elderly patient?
- A. Keeping the room brightly lit
- B. Administering sedatives as needed
- C. Encouraging family presence
- D. Restricting fluids
Correct answer: C
Rationale: Encouraging family presence is the most appropriate intervention for managing delirium in elderly patients. This intervention provides orientation, reassurance, and comfort, which can help reduce confusion and anxiety, thus aiding in managing delirium. Keeping the room brightly lit (Choice A) may worsen delirium as it can disrupt the patient's sleep-wake cycle. Administering sedatives (Choice B) should be avoided unless absolutely necessary due to the risk of worsening delirium. Restricting fluids (Choice D) is not a recommended intervention for managing delirium, as hydration is important for overall patient well-being.
2. A client is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hypotension
- B. Polyuria
- C. Bilateral crackles
- D. Hyperglycemia
Correct answer: C
Rationale: The correct answer is C: Bilateral crackles. Bilateral crackles indicate respiratory complications, which can occur as an adverse effect of an epidural block with opioid analgesics. Hypotension (Choice A) is a common side effect of epidural opioids but is not typically monitored via crackles. Polyuria (Choice B) is excessive urination and is not directly associated with epidural blocks. Hyperglycemia (Choice D) is high blood sugar levels and is not a typical adverse effect of epidural opioids.
3. How should hydration status in a child with fever and vomiting be assessed?
- A. Monitor skin turgor and mucous membranes
- B. Measure blood glucose levels
- C. Check for signs of jaundice
- D. Assess respiratory rate
Correct answer: A
Rationale: To assess hydration status in a child with fever and vomiting, monitoring skin turgor and mucous membranes is essential. Skin turgor refers to the skin's ability to change shape and return to normal; poor skin turgor can indicate dehydration. Mucous membranes, such as the mouth and eyes, can also provide valuable information about hydration levels. Measuring blood glucose levels (Choice B) is not directly related to assessing hydration status. Checking for signs of jaundice (Choice C) is important for liver-related issues, not hydration assessment. Assessing respiratory rate (Choice D) is crucial for evaluating respiratory function, not hydration status.
4. Rehabilitation after illness is classified under which level of healthcare?
- A. Primary
- B. Secondary
- C. Tertiary
- D. All three
Correct answer: C
Rationale: Rehabilitation after illness is classified as tertiary care. Tertiary care aims to help patients recover from illness, injuries, or disabilities, and restore their functionality. Primary care involves preventive measures and early disease detection, while secondary care focuses on diagnosis and treatment of specific conditions. Therefore, choices A, B, and D are incorrect as they do not specifically address the specialized nature of rehabilitation in healthcare.
5. A nurse is caring for a client who requests information about the prevalence of Tay-Sachs disease. Which of the following resources should the nurse use to obtain this information?
- A. The client's health care provider
- B. A collaborative, user-edited website
- C. The facility's case manager
- D. An evidence-based nursing journal
Correct answer: D
Rationale: An evidence-based nursing journal is the correct choice for the nurse to obtain information about the prevalence of Tay-Sachs disease. These journals contain peer-reviewed research and studies conducted by experts in the field, providing accurate and reliable information. Choice A, the client's health care provider, may have general information but may not provide detailed prevalence data. Choice B, a collaborative, user-edited website, is not a reliable source as the information may be inaccurate or outdated. Choice C, the facility's case manager, is unlikely to have specific prevalence data on Tay-Sachs disease.