HESI LPN
HESI PN Exit Exam 2023
1. While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?
- A. Swab the oral cavity with a washcloth
- B. Use oral swabs with normal saline
- C. Provide a Yankauer tip for oral suction
- D. Support the head with a small pillow
Correct answer: B
Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.
2. A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
- A. Take all prescribed antibiotics as directed.
- B. Avoid crowded places and people who are sick.
- C. Wash hands frequently and practice good hygiene.
- D. Keep the surgical site clean and dry.
Correct answer: C
Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (Choice A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (Choice B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (Choice D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.
3. Which of the following is a priority for the nurse to include in the teaching of a client who was recently prescribed alprazolam (Xanax) as an oral medication?
- A. Monitor heart rate before taking the medication
- B. Monitor temperature daily
- C. Avoid unprotected exposure to sunlight
- D. Avoid alcohol
Correct answer: D
Rationale: The correct answer is D: 'Avoid alcohol.' Alprazolam (Xanax) can have central nervous system depressant effects, which are exacerbated by alcohol. It is crucial to avoid alcohol while taking this medication to prevent severe sedation and respiratory depression. Monitoring heart rate (choice A) is not directly related to alprazolam administration. Monitoring temperature daily (choice B) is not a priority teaching point for a client prescribed alprazolam. Avoiding unprotected exposure to sunlight (choice C) is not specifically linked to the use of alprazolam.
4. Which disorder is characterized by demyelination of neurons in the central nervous system?
- A. Multiple sclerosis
- B. Parkinson's disease
- C. Alzheimer's disease
- D. Huntington's disease
Correct answer: A
Rationale: Multiple sclerosis is the correct answer. It is an autoimmune disease that specifically targets and damages the myelin sheath surrounding neurons in the central nervous system. This demyelination disrupts the transmission of nerve signals and leads to a variety of neurological symptoms. Parkinson's disease (Choice B), Alzheimer's disease (Choice C), and Huntington's disease (Choice D) are neurodegenerative disorders that do not primarily involve demyelination of neurons in the CNS. Parkinson's disease is characterized by the loss of dopamine-producing neurons, Alzheimer's disease by the formation of plaques and tangles in the brain, and Huntington's disease by a genetic mutation affecting nerve cells.
5. Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?
- A. How much exercise did the child have today?
- B. Did the child perform a finger stick?
- C. When did the child last urinate?
- D. Has the child eaten recently?
Correct answer: B
Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.
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