HESI LPN
HESI PN Exit Exam 2023
1. While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?
- A. Impaired verbalization
- B. Depressed mood
- C. Flat affect
- D. Diminished LOC
Correct answer: C
Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.
2. While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, what should you do next?
- A. massage the uterus to facilitate delivery of the fetus
- B. relieve pressure from the cord with your gloved fingers
- C. place the mother on her left side and provide rapid transport
- D. elevate the mother's lower extremities and provide immediate transport
Correct answer: B
Rationale: In the scenario described, the priority is to relieve pressure from the umbilical cord protruding from the vaginal opening by gently pushing it back inside using your gloved fingers. This action helps prevent cord compression, maintains blood flow to the fetus, and ensures fetal oxygenation. Massaging the uterus (Choice A) is not appropriate in this situation as it can potentially worsen the cord compression. Placing the mother on her left side and providing rapid transport (Choice C) can be considered after relieving the pressure on the cord. Elevating the mother's lower extremities and providing immediate transport (Choice D) is not the correct approach when dealing with a visible umbilical cord; instead, the focus should be on relieving pressure from the cord to prevent fetal compromise.
3. After a cardiac catheterization, what is the priority nursing care for a 3-year-old child?
- A. Encouraging early ambulation
- B. Monitoring the site for bleeding
- C. Restricting fluids until the blood pressure is stabilized
- D. Comparing the blood pressure of both lower extremities
Correct answer: B
Rationale: The priority nursing care after a cardiac catheterization in a 3-year-old is to monitor the site for bleeding. This is essential to promptly detect and manage any potential complications, such as hematoma or hemorrhage. Encouraging early ambulation, as mentioned in choice A, may not be safe immediately post-procedure and should be guided by the healthcare provider's instructions. Restricting fluids until blood pressure is stabilized, as in choice C, is not typically necessary after a cardiac catheterization. Comparing blood pressure in both lower extremities, as in choice D, is not the priority immediate nursing care following this procedure.
4. What should be included in the medical management of sickle cell crisis?
- A. Information for the parents including home care
- B. Provisions for adequate hydration and pain management
- C. Pain management and administration of iron supplements
- D. Adequate oxygenation and factor VIII
Correct answer: B
Rationale: The correct answer is B: Provisions for adequate hydration and pain management. In managing a sickle cell crisis, it is essential to provide adequate hydration to prevent further sickling of red blood cells and ensure proper pain management to alleviate the severe pain associated with the crisis. While information for parents and home care may be important aspects of overall care, they are not specific to the immediate medical management of a sickle cell crisis. Administration of iron supplements is not recommended during a sickle cell crisis as it can potentially worsen the condition by promoting the production of more sickled red blood cells. Adequate oxygenation is crucial in sickle cell disease, but factor VIII is not typically part of the management of a sickle cell crisis.
5. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate
- B. Maintain the space between the numerical dose and the unit of measure
- C. Note the dosage of insulin in units
- D. Use 'subcut' for indicating a subcutaneous injection
Correct answer: A
Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.