at one minute after birth an infant is crying has a heart rate of 140 has acrocyanosis resists the suction catheter and keeps his arms extended and hi
Logo

Nursing Elites

HESI LPN

HESI PN Exit Exam 2024

1. At one minute after birth, an infant is crying, has a heart rate of 140, has acrocyanosis, resists the suction catheter, and keeps his arms extended and his legs flexed. What is the Apgar score?

Correct answer: C

Rationale: The Apgar score is based on five components: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the infant has a heart rate over 100 (2 points), is crying (2 points indicating good respiratory effort), resists the catheter (2 points for good reflex irritability), but has acrocyanosis (partial point deduction of 1). Thus, the Apgar score at one minute after birth would be 8. Choice A is incorrect as the given signs indicate a higher score. Choice B is incorrect as the signs described support a score above 6. Choice D is incorrect as it represents a perfect score which is not the case here due to acrocyanosis.

2. A client with peripheral neuropathy due to cirrhosis is at risk for injury. What should the nurse do?

Correct answer: A

Rationale: Protecting the client's feet from injury is critical as peripheral neuropathy can lead to decreased sensation and increased risk of trauma. This measure helps prevent wounds, ulcers, and other complications. Applying a heating pad (Choice B) can worsen symptoms and cause burns due to decreased sensation. Keeping the client's feet elevated (Choice C) may help reduce swelling but does not directly address the risk of injury. Assessing for jaundice (Choice D) is important in cirrhosis but is not directly related to the client's risk of injury due to peripheral neuropathy.

3. A client who is receiving chemotherapy has developed stomatitis. Which instruction should the nurse provide the UAP who is assisting with the care of this client?

Correct answer: D

Rationale: Providing gentle and meticulous mouth care is critical for a client with stomatitis as it helps prevent further irritation and infection of the mucous membranes. Keeping the room environment free of unpleasant odors (Choice A) is important for the client's comfort but not directly related to managing stomatitis. Gathering supplies for protective environmental precautions (Choice B) is not relevant to addressing stomatitis. Assisting the client with feeding at meal times (Choice C) is important for overall care but does not specifically target the care needed for stomatitis.

4. The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?

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.

5. What is the most common cause of hyperthyroidism?

Correct answer: A

Rationale: Corrected Rationale: Graves' disease is the most common cause of hyperthyroidism. It is characterized by an overactive thyroid gland due to autoantibodies stimulating the thyroid. Hashimoto's thyroiditis is actually a cause of hypothyroidism, not hyperthyroidism. Thyroid nodules and pituitary adenoma are not common causes of hyperthyroidism.

Similar Questions

Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?
A nurse is reviewing the basal body temperature method with a couple. Which of the following statements would indicate that the teaching has been successful?
A nurse is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the nurse document in the medical record?
A client presents to the office with complaints of swelling in the legs, chills, and shortness of breath. During auscultation of the chest, a heart murmur is heard. The client's blood culture reveals a microorganism in the blood. When a microorganism is found in the blood, this condition is called
Which task could the PN safely delegate to the UAP?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses