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. An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units in the morning. Which finding should the nurse document as evidence that the amount of insulin is inadequate?
- A. States that her feet are constantly cold and numb
- B. A wound on the ankle that starts to drain and becomes painful
- C. Consecutive evening serum glucose greater than 260 mg/dL
- D. Reports nausea in the morning but still able to eat breakfast
Correct answer: C
Rationale: The correct answer is C. Consistently high evening glucose levels indicate that the current insulin dosage is inadequate to maintain proper glucose control. Choice A is incorrect because cold and numb feet are more indicative of peripheral vascular disease rather than inadequate insulin dosage. Choice B describes a wound that may be related to poor circulation or neuropathy but not necessarily inadequate insulin dosage. Choice D suggests gastrointestinal issues that are not directly related to insulin dosage adequacy.
3. There has been a serious explosion at a local factory, and many of the injured are arriving at the hospital. Which of the following patients should a nurse attend to first?
- A. A 30-year-old male who is able to walk into the hospital on his own but has numerous lacerations on the chest and face
- B. A 45-year-old male who was brought in on a stretcher, has been assessed as having respiration and circulation within normal limits, and can follow simple commands
- C. A 50-year-old woman who can walk but has a broken arm and numerous lacerations
- D. A 19-year-old man who has numerous lacerations all over the body and whose respiration exceeds 30 breaths per minute
Correct answer: D
Rationale: The correct answer is D. The 19-year-old man with a respiration rate exceeding 30 breaths per minute is showing signs of respiratory distress, indicating a potentially life-threatening condition that requires immediate attention. Patients with respiratory distress should be prioritized as it is a critical condition. Choices A, B, and C describe patients with injuries that are less immediately life-threatening or who are more stable based on the provided information, so they can be attended to after the patient with respiratory distress. Therefore, the nurse should attend to the 19-year-old man first to address his respiratory distress and ensure his condition does not deteriorate further.
4. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?
- A. Avoid lifting heavy objects for at least a week.
- B. Follow a low-fat diet.
- C. Monitor the incision sites for signs of infection.
- D. Resume normal activities as tolerated.
Correct answer: C
Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.
5. A client confides to the nurse that the client has been substituting herbal supplements for high blood pressure instead of the prescribed medication. How should the nurse respond first?
- A. Ask the client's reason for choosing to take herbs instead of prescribed medication
- B. Reinforce that the healthcare provider prescribed the medication for a reason
- C. Have the client use their own words to describe complications of high blood pressure
- D. Point out the risks of not taking the prescribed medication rather than herbal supplements
Correct answer: A
Rationale: The correct answer is to ask the client's reason for choosing to take herbs instead of prescribed medication. Understanding the client's rationale for using herbal supplements allows the nurse to explore any misconceptions and provide education on the importance of the prescribed medication. Choice B is incorrect because simply reinforcing the prescription does not address the client's concerns or reasons for using herbal supplements. Choice C does not directly address the immediate concern of the client substituting medication with herbal supplements. Choice D focuses on the risks of not taking the prescribed medication rather than herbal supplements, which is not the most appropriate initial response.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99