HESI LPN
HESI PN Exit Exam 2023
1. What is the first action a healthcare professional should take when a patient’s nasogastric (NG) tube becomes clogged?
- A. Flush the tube with water
- B. Reposition the patient
- C. Attempt to aspirate the clog with a syringe
- D. Administer a medication to dissolve the clog
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.
2. A client presents to the office with complaints of swelling in the legs, chills, and shortness of breath. During auscultation of the chest, a heart murmur is heard. The client's blood culture reveals a microorganism in the blood. When a microorganism is found in the blood, this condition is called
- A. Bacteremia
- B. Sepsis
- C. Septicemia
- D. Parasitic infection
Correct answer: A
Rationale: When a microorganism is found in the blood, this condition is called bacteremia, which refers to the presence of bacteria in the bloodstream, as indicated by a positive blood culture. If not appropriately treated, bacteremia can progress to septicemia, also known as sepsis. Sepsis is a severe and life-threatening response to an infection, characterized by systemic inflammation and organ dysfunction. Parasitic infections involve pathogens other than bacteria and are not directly related to the scenario described.
3. What is the primary purpose of administering Rho(D) immune globulin (RhoGAM) to an Rh-negative mother after childbirth?
- A. To prevent Rh sensitization in future pregnancies
- B. To treat anemia in the newborn
- C. To increase the mother's white blood cell count
- D. To prevent infection in the newborn
Correct answer: A
Rationale: The correct answer is A: To prevent Rh sensitization in future pregnancies. RhoGAM is given to an Rh-negative mother to prevent the development of antibodies against Rh-positive blood cells. This prevents Rh sensitization, which could lead to hemolytic disease in future Rh-positive pregnancies. Choices B, C, and D are incorrect because RhoGAM is not used to treat anemia in the newborn, increase the mother's white blood cell count, or prevent infection in the newborn.
4. An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?
- A. No bowel movement for two days
- B. Mother helps reposition the child
- C. Ensure weights are not touching the foot of the bed
- D. Child wiggles toes freely when tickled
Correct answer: C
Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.
5. What is the correct order of steps in the nursing process?
- A. Assessment, Diagnosis, Planning, Implementation, Evaluation
- B. Planning, Implementation, Evaluation, Diagnosis, Assessment
- C. Diagnosis, Assessment, Planning, Implementation, Evaluation
- D. Implementation, Planning, Evaluation, Diagnosis, Assessment
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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