HESI LPN
HESI PN Exit Exam 2024 Quizlet
1. The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?
- A. Ask her to share how the injury occurred to her child.
- B. Recommend that she remain calm and positive for her child.
- C. Express that the present situation must be overwhelming.
- D. Determine if someone else can help her cope with this tragedy.
Correct answer: C
Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.
2. A nurse is assessing a day-old infant for jaundice. Which of the following is the best method for this?
- A. Applying pressure over a bony area such as the forehead and evaluating the skin color after the pressure is removed
- B. Assessing the color of the infant’s hands and feet
- C. Assessing the infant’s tongue
- D. Assessing the infant’s arms and legs
Correct answer: A
Rationale: The correct answer is A. Applying pressure over a bony area and evaluating the skin color after the pressure is removed is the most accurate method for assessing jaundice in a day-old infant. This technique helps in identifying any yellowing of the skin, which is a key indicator of jaundice. Choices B, C, and D are less effective methods for assessing jaundice in a newborn. Assessing the color of the hands and feet may not give a reliable indication of jaundice, while evaluating the tongue, arms, and legs are not as specific or accurate as applying pressure over a bony area.
3. Which action should the PN implement when using standard precautions to provide client care?
- A. Apply sterile gloves to obtain a finger stick blood sample
- B. Wear clean exam gloves to perform perineal catheter care
- C. Replace the needle cap after giving an intramuscular injection
- D. Wear a paper gown to prevent transmission of droplet pathogens
Correct answer: B
Rationale: The correct answer is B. When using standard precautions, healthcare providers should wear clean exam gloves to perform perineal catheter care. This approach helps prevent the transmission of pathogens and ensures the safety of both the client and the healthcare provider. Choice A is incorrect because applying sterile gloves for a finger stick blood sample is unnecessary when non-sterile gloves would suffice. Choice C is incorrect because replacing the needle cap after giving an intramuscular injection is not directly related to standard precautions. Choice D is incorrect because wearing a paper gown is not a standard precaution for preventing the transmission of droplet pathogens.
4. After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?
- A. Remove the air from the solution bag
- B. Obtain a piston syringe and irrigation set
- C. Record the solution added as fluid intake
- D. Calculate the rate of flow of the solution
Correct answer: B
Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.
5. The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?
- A. Ask a regular staff member to confirm the resident's identity
- B. Hold the medication until a family member can confirm identity
- C. Re-orient the resident to name, place, and situation
- D. Confirm the room and bed numbers with those on the medication record
Correct answer: A
Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.
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