HESI LPN
HESI PN Exit Exam 2024
1. In which stage of Maslow's hierarchy of needs is a young adult attempting to achieve when deciding to change his work hours to devote more time to his community?
- A. Self-Actualization
- B. Intimacy vs. Isolation
- C. Altruism
- D. Purposefulness
Correct answer: A
Rationale: The correct answer is A: Self-Actualization. The young adult is striving for self-actualization, the highest level in Maslow's hierarchy of needs. Self-actualization is characterized by individuals seeking personal growth, self-fulfillment, and the ability to contribute to society. Choice B, Intimacy vs. Isolation, focuses on relationships and occurs at a different stage. Choice C, Altruism, although related to community contribution, does not specifically address personal growth and fulfillment as in self-actualization. Choice D, Purposefulness, is not a stage in Maslow's hierarchy of needs and is not directly relevant to the scenario described.
2. A 12-year-old child is receiving a blood transfusion via an infusion pump and begins to complain of 'itchy' skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the nurse take first?
- A. Apply lotion to the skin
- B. Stop the transfusion
- C. Inspect the infusion site
- D. Obtain the vital signs
Correct answer: B
Rationale: Stopping the transfusion immediately is crucial when signs of a transfusion reaction, such as itching and flushing, occur. This action is taken to prevent further exposure to the potentially harmful transfused blood. Applying lotion to the skin, inspecting the infusion site, or obtaining vital signs can be important but are secondary to stopping the transfusion to ensure the safety of the child. Applying lotion may not address the underlying issue of a possible transfusion reaction. Inspecting the infusion site and obtaining vital signs can be done after stopping the transfusion, as patient safety is the top priority in this situation.
3. Which of the following areas does the Patient’s Bill of Rights cover?
- A. Information disclosure
- B. Choice of providers
- C. Choice of plans
- D. All of the above
Correct answer: D
Rationale: The Patient’s Bill of Rights encompasses various areas to protect patients' rights. These include ensuring information disclosure, allowing patients to choose their healthcare providers, and giving them options to select plans that suit their needs. Therefore, all the choices - information disclosure, choice of providers, and choice of plans - are covered under the Patient’s Bill of Rights. The option 'Best payment options' is not relevant to the areas typically addressed by the Patient’s Bill of Rights.
4. A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?
- A. Document the finding and continue to monitor.
- B. Apply warm compresses to the stoma.
- C. Notify the healthcare provider immediately.
- D. Encourage the client to ambulate.
Correct answer: C
Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.
5. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the nurse who is taking the client's vital signs. What action should the nurse implement?
- A. Notify the healthcare provider or charge nurse immediately
- B. Offer to reschedule the treatment for the following week
- C. Plan to monitor the client's vital signs every 30 minutes
- D. Reinforce the need for extra rest periods and plenty of sleep
Correct answer: D
Rationale: Fatigue is a common side effect of radiation therapy. In this scenario, the appropriate action for the nurse to take is to reinforce the importance of rest and adequate sleep. It is crucial to address the client's increasing fatigue by promoting self-care strategies such as additional rest periods and ensuring plenty of sleep. Rescheduling the treatment is not necessary for fatigue, and vital sign monitoring every 30 minutes may not directly address the client's reported symptom. Notifying the healthcare provider or charge nurse immediately is not the first-line intervention for increasing fatigue, as this symptom can be managed through education and self-care recommendations.
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