HESI LPN
HESI PN Exit Exam
1. 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.
2. A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers questions with one or two-word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important for the PN to implement?
- A. Persuade the client to lie down
- B. Provide a drink high in electrolytes
- C. Observe the client during the shift
- D. Measure appropriate vital signs
Correct answer: D
Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.
3. The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?
- A. Swollen and discolored penile shaft
- B. Prepuce extends over the head of the penis
- C. Leaking urine around the top of the catheter
- D. Moist and excoriated perineal skin folds
Correct answer: A
Rationale: The correct answer is A: Swollen and discolored penile shaft. Swelling and discoloration of the penile shaft may indicate an infection or other complications requiring immediate attention. Prompt reporting allows for timely intervention to prevent further harm to the client. Choice B is incorrect because the prepuce extending over the head of the penis is not an urgent issue. Choice C, leaking urine around the catheter, may require intervention but is not as urgent as the swelling and discoloration described in choice A. Choice D, moist and excoriated perineal skin folds, also needs attention but is not as concerning as the potential complications indicated by the findings in choice A.
4. A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse’s priority action?
- A. Administer pain medication.
- B. Lay the client flat and notify the healthcare provider.
- C. Encourage the client to drink more fluids.
- D. Assess the client’s surgical site for drainage.
Correct answer: B
Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.
5. When teaching a patient about the side effects of a new medication, which teaching method is most effective?
- A. Providing a written pamphlet
- B. Giving verbal instructions only
- C. Demonstrating how to take the medication
- D. Using a combination of verbal, written, and demonstration methods
Correct answer: D
Rationale: The most effective teaching method when educating a patient about the side effects of a new medication is to use a combination of verbal, written, and demonstration methods. This comprehensive approach ensures that the patient receives information through multiple channels, catering to different learning styles. Verbal instructions allow for direct communication, written materials provide a reference for the patient to review later, and demonstrations offer a visual aid that can enhance understanding. Providing a combination of these methods increases the likelihood of the patient retaining and comprehending the information effectively. Choices A, B, and C are less effective as they do not encompass the benefits of utilizing multiple teaching modalities.
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