HESI LPN
HESI PN Exit Exam 2024
1. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?
- A. Protect the client's feet from injury
- B. Apply a heating pad to affected area
- C. Keep the client's feet elevated
- D. Assess the feet and legs for jaundice
Correct answer: A
Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.
2. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?
- A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
- B. Assessing the color of the infant’s hands and feet
- C. Assessing the infant’s tongue
- D. Assessing the infant’s arms and legs
Correct answer: A
Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.
3. A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?
- A. Continuous bubbling in the water seal chamber indicates an air leak.
- B. Continuous bubbling is normal and expected with a chest tube.
- C. Bubbling will stop when the lung has fully expanded.
- D. The nurse should notify the healthcare provider immediately.
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.
4. The PN observes a UAP preparing to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take?
- A. Confirm that the UAP completed hand hygiene correctly
- B. Instruct the UAP to wash the hands for one minute
- C. Ask the UAP why the hands were so obviously soiled
- D. Advise the UAP to use the hand rub for 30 seconds
Correct answer: D
Rationale: When hands are visibly soiled, they should be washed with soap and water for at least 20 seconds. However, when using hand rub, it should be applied for at least 30 seconds to be effective. In this scenario, the UAP's hands were visibly soiled, indicating the need for thorough cleaning. Advising the UAP to use the hand rub for 30 seconds is essential to ensure proper hand hygiene and reduce the risk of spreading infection. Choices A, B, and C are incorrect because confirming completion of hand hygiene, instructing to wash for one minute, or asking why the hands were soiled do not address the immediate need for proper hand hygiene in the given situation.
5. An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?
- A. No bowel movement for two days
- B. Mother helps reposition the child
- C. Ensure weights are not touching the foot of the bed
- D. Child wiggles toes freely when tickled
Correct answer: C
Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.
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