during a routine prenatal visit at the antepartal clinic a multipara at 35 weeks gestation presents with 2 edema of the ankles and edema which additio
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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?

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. A nurse is completing a focused assessment of an older adult's skin. The nurse notes a crusted 0.7 cm lesion on the client's forehead. Which action should the nurse take in response to this finding?

Correct answer: A

Rationale: A crusted lesion, especially in an older adult, could be indicative of skin cancer or another serious condition. Therefore, reporting this finding to the healthcare provider is crucial for further evaluation and appropriate management. Placing an occlusive dressing (Choice B) could prevent proper assessment and treatment. Applying a warm compress (Choice C) may not be suitable for a suspicious skin lesion as it could worsen the condition. Explaining it as a normal skin change (Choice D) without proper evaluation can delay necessary interventions and potentially harm the patient.

3. When teaching a patient with diabetes about foot care, which of the following should the nurse emphasize?

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across and filing the edges is crucial in diabetic foot care to prevent ingrown toenails and foot injuries. Soaking feet daily can lead to dryness and skin breakdown, increasing the risk of infection. Selecting well-fitting shoes is important to prevent pressure points and skin damage, not tight-fitting shoes. Using heating pads can result in burns or injuries due to decreased sensation in diabetic feet, so it's essential to avoid them.

4. What is an essential nursing action before administering a blood transfusion?

Correct answer: B

Rationale: Verifying the blood type and patient identity with another nurse is crucial before administering a blood transfusion. This step helps prevent transfusion reactions and ensures that the correct blood is given to the right patient. Checking the patient’s blood pressure, although important, is not directly related to verifying blood type and patient identity. Flushing the IV line with saline is a good practice but is not as critical as confirming the blood type and patient identity. Administering pre-transfusion medications would come after verifying the blood type and patient identity.

5. A client who had a thyroidectomy 24 hours ago reports tingling around the mouth and in the fingertips. What should the nurse do first?

Correct answer: A

Rationale: Tingling around the mouth and in the fingertips can indicate hypocalcemia, a potential complication after thyroidectomy due to accidental damage to the parathyroid glands. Checking calcium levels is crucial as it helps in diagnosing hypocalcemia accurately. Administering calcium without knowing the actual calcium levels can be dangerous. Assessing the incision site for bleeding is important but not the priority in this situation. Notifying the healthcare provider can be done after assessing and managing the immediate concern of hypocalcemia.

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