what intervention should the pn implement when taking the rectal temperature of an adult client
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HESI LPN

HESI PN Exit Exam

1. What intervention should the PN implement when taking the rectal temperature of an adult client?

Correct answer: C

Rationale: When taking a rectal temperature, it is essential to hold the thermometer in place the entire time to ensure safety, accuracy, and prevent the thermometer from slipping out. Choice A, lubricating the tip of the thermometer with a water-based gel, is important for comfort and ease of insertion. Choice B, gently inserting the thermometer 1 inch into the rectum, is more accurate for adults than inserting it 3 inches. Choice D, placing the client in the left lateral position, is not necessary for a rectal temperature measurement.

2. At what age does a 9-year-old child typically lose which of the following teeth?

Correct answer: A

Rationale: A 9-year-old child typically loses their central incisors, not the lateral incisors or second molars. The central incisors are usually among the first teeth that children lose around 6 to 7 years of age, as part of the natural process of shedding primary teeth to make way for permanent teeth. The second molars and cuspids are typically lost later in the mixed dentition phase. Therefore, option A, 'Central incisor,' is the correct answer.

3. What is the first action a healthcare professional should take when a patient’s nasogastric (NG) tube becomes clogged?

Correct answer: C

Rationale: When a patient's nasogastric (NG) tube becomes clogged, the first action to take is to attempt to aspirate the clog with a syringe. This is a standard and initial step to clear the blockage in the tube. Flushing the tube with water (Choice A) may not address the specific clog; repositioning the patient (Choice B) is not directly related to clearing the tube. Administering a medication to dissolve the clog (Choice D) should only be considered after simpler methods like aspiration have been attempted.

4. When caring for a child with sickle cell disease, the PN expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?

Correct answer: B

Rationale: During a sickle cell crisis, a child with sickle cell disease is most likely to describe joint pain. Sickle cell disease leads to the blockage of blood flow by sickled red blood cells, causing ischemia and pain, often felt in the joints and other body parts. Fatigue (choice C) is a nonspecific symptom that can occur in various conditions but is not a characteristic symptom of a sickle cell crisis. While decreased hemoglobin (choice A) can be observed in sickle cell disease, it is not a symptom typically described by a child during a sickle cell crisis. Infection (choice D) can trigger a sickle cell crisis but is not the symptom most likely to be described by the child during the crisis.

5. What is the correct order of steps in the nursing process?

Correct answer: A

Rationale: The correct order in the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment involves gathering information about the patient, Diagnosis is identifying the problem, Planning involves setting goals and outcomes, Implementation is carrying out the plan, and Evaluation is assessing the outcomes. Choices B, C, and D have the steps in the incorrect order, not following the standard nursing process framework. Therefore, the correct answer is option A.

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