HESI LPN
HESI PN Exit Exam 2024
1. A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse’s best action?
- A. Administer a prescribed laxative.
- B. Encourage the client to increase fluid intake.
- C. Auscultate bowel sounds.
- D. Notify the healthcare provider.
Correct answer: C
Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.
2. When preparing a sterile field for a procedure, which action should the nurse take to maintain sterility?
- A. Place sterile items around the sterile field
- B. Keep hands below waist level to avoid contamination
- C. Open the sterile package away from the body
- D. Avoid reaching over the sterile field
Correct answer: D
Rationale: To maintain sterility when preparing a sterile field, it is essential to avoid reaching over the sterile field. This action can introduce contaminants from the nurse's clothing or unsterile areas, compromising the sterility of the field. Placing sterile items around the sterile field (choice A) is incorrect as it may increase the risk of contamination by extending the area where non-sterile items may come in contact. Keeping hands below waist level (choice B) is also incorrect as it does not prevent contamination effectively. Opening the sterile package away from the body (choice C) is incorrect since it exposes the contents to the nurse's body, which is not sterile.
3. Which assessment finding would most likely indicate a complication of enteral tube feeding?
- A. Abdominal distension
- B. Weight gain
- C. Decreased bowel sounds
- D. Diarrhea
Correct answer: A
Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.
4. Which condition is most commonly associated with a "bull's eye" rash?
- A. Lyme disease
- B. Rocky Mountain spotted fever
- C. Syphilis
- D. Toxoplasmosis
Correct answer: A
Rationale: The correct answer is A: Lyme disease. The "bull's eye" rash, or erythema migrans, is a hallmark of early Lyme disease, caused by the bacterium Borrelia burgdorferi. Choice B, Rocky Mountain spotted fever, presents with a different type of rash. Choice C, Syphilis, typically presents with a painless ulcer and rash but not a "bull's eye" rash. Choice D, Toxoplasmosis, does not typically present with a "bull's eye" rash.
5. The HCP gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her that she needs to increase foods in her diet because her hemoglobin is 8.2 grams/dL. When a list of iron-rich foods is given to the client, she tells the PN that she is a vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide?
- A. All below
- B. Increase green leafy vegetables in the diet
- C. Oatmeal is a good choice for breakfast
- D. Add lentils and black beans to soup
Correct answer: A
Rationale: Vegetarians can increase their iron intake through plant-based sources such as green leafy vegetables, oatmeal, and legumes, which are rich in iron.
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