the nurse is assigned to care for an older male client who is recovering from a stroke when assisting this client to ambulate with the use of a cane w
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Nursing Elites

HESI LPN

HESI PN Exit Exam

1. When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?

Correct answer: B

Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.

2. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

3. According to the principle of asepsis, which situation should the PN consider to be sterile?

Correct answer: A

Rationale: According to the principle of asepsis, the one-inch border around the edges of a sterile field set up in the operating room is considered non-sterile, while the central area remains sterile. Therefore, the PN should consider the situation described in choice A to be sterile. Choice B is incorrect because a glove that may have touched hair is contaminated. Choice C is incorrect as a sterile item placed on a damp surface is considered contaminated. Choice D is incorrect as a sterile kit set up at the PN's waist level is prone to contamination.

4. The mother of a 9-month-old child diagnosed with respiratory syncytial virus (RSV) yesterday calls the clinic to inquire if it will be all right to take her infant to a friend's child's first birthday party the following day. Which response should the nurse provide?

Correct answer: A

Rationale: The correct response is A: 'Do not expose other children as the virus is very contagious even without direct contact.' RSV is highly contagious, especially in young children. Allowing the infected child to attend a birthday party can put other children at risk of contracting the virus. Choice B is incorrect as RSV can remain contagious for a period of time. Choice C is not sufficient, as wearing a mask may not entirely prevent the spread of the virus. Choice D is inaccurate, as children under 5 months are not the only ones susceptible to RSV; all young children are at risk.

5. The PN assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the PN provide the UAP?

Correct answer: B

Rationale: During an acute exacerbation of multiple sclerosis, it is important to encourage self-care to maintain the client's independence. Allowing rest periods helps prevent fatigue, which is crucial in managing MS exacerbations. Choice A is incorrect as hot baths can exacerbate symptoms in MS. Choice C is about communication techniques and not directly related to client care during an exacerbation. Choice D is not a priority intervention during an MS exacerbation.

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