HESI LPN
HESI PN Exit Exam
1. During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN?
- A. Due date
- B. Blood pressure
- C. Gravida and parity
- D. Fundal height
Correct answer: B
Rationale: Blood pressure is the most critical information to report to the RN in this scenario. The presence of edema, along with high blood pressure, can be indicative of preeclampsia, a severe condition in pregnancy. Monitoring blood pressure is essential for assessing the patient's condition and taking appropriate actions if necessary. Choices A, C, and D are not as urgent in this situation. The due date, gravida, and parity are important for overall assessment but do not address the immediate concern of potential preeclampsia. Fundal height is used to assess fetal growth and position but is not the priority when edema and high blood pressure are present.
2. The PN notes that a UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take?
- A. Instruct the UAP to walk on the client's affected side
- B. Take over the ambulation and provide guidance to the UAP immediately
- C. Provide the client with an assistive device, such as a cane or walker
- D. Tell the UAP to take the client back to his room
Correct answer: A
Rationale: The correct action for the PN to take is to instruct the UAP to walk on the client’s affected side. This is essential to provide the necessary support and prevent falls, especially when the client has weakness on one side due to a stroke. Walking on the affected side helps provide stability and assistance to the weaker side. Choice B is incorrect because it would be more appropriate for the PN to provide immediate guidance and correct the UAP's positioning rather than taking over the task completely. Choice C is incorrect because while assistive devices may be beneficial, the immediate concern is the UAP's positioning during ambulation, not providing the client with an assistive device. Choice D is incorrect as there is no indication to return the client to his room unless it is necessary for his safety or well-being.
3. The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?
- A. Ask another nurse to return with the medication when the client has hung up the phone
- B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
- C. Return the medication to the client's drawer on the cart and document that the client refused the dose
- D. Leave the medication with the client and let him take it when he finishes the conversation
Correct answer: B
Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.
4. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Assist the client back to the room
- C. Have the client sit down in the hall
- D. Obtain a 12-lead electrocardiogram
Correct answer: C
Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.
5. Which neurotransmitter is most closely associated with mood regulation and is targeted by antidepressants?
- A. Serotonin
- B. Dopamine
- C. GABA
- D. Acetylcholine
Correct answer: A
Rationale: The correct answer is A: Serotonin. Serotonin plays a vital role in mood regulation, and its imbalance is often associated with depression. Many antidepressants function by boosting serotonin levels in the brain. Dopamine (Choice B) is more linked to reward and pleasure pathways in the brain, not primarily targeted for mood regulation. GABA (Choice C) is an inhibitory neurotransmitter that helps reduce neuronal excitability, not primarily associated with mood regulation. Acetylcholine (Choice D) is involved in muscle movement and cognitive functions, not the primary target of antidepressants for mood regulation.
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