HESI LPN
HESI PN Exit Exam
1. What is the primary function of surfactant in the lungs?
- A. Reduce surface tension
- B. Enhance oxygen absorption
- C. Facilitate carbon dioxide release
- D. Increase lung volume
Correct answer: A
Rationale: The primary function of surfactant in the lungs is to reduce surface tension in the alveoli. This reduction in surface tension prevents lung collapse and allows for easier breathing. It is particularly crucial in premature infants to help with lung expansion. Choice B is incorrect because surfactant primarily affects surface tension, not oxygen absorption. Choice C is incorrect because surfactant's main role is not in facilitating carbon dioxide release. Choice D is incorrect because surfactant does not directly increase lung volume; its main role is in reducing surface tension.
2. A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take?
- A. Ensure that all the areolar tissue of the nipple is in the infant's mouth
- B. Have the mother reposition the infant from the cradle to the football hold
- C. Check for engorgement and assess the nipples for cracks or lesions
- D. Apply a warm compress to the breast for 10 minutes before each feeding
Correct answer: A
Rationale: Proper latch, including all the areolar tissue in the infant's mouth, is essential to prevent nipple pain and ensure effective breastfeeding. Option A is correct because ensuring that all the areolar tissue of the nipple is in the infant's mouth helps achieve a good latch, reducing nipple pain. Option B is incorrect as repositioning the infant may not address the root cause of the pain related to latch issues. Option C is incorrect because while checking for engorgement and nipple issues is important, it does not directly address the latch concern causing the pain. Option D is incorrect as applying a warm compress is not recommended for breastfeeding mothers; a warm compress can help with pain associated with engorgement, but it does not address latch issues.
3. A client is complaining of a tingling sensation in the fingers, nose tip, and earlobes 24 hours after a total thyroidectomy. Which measure should the PN implement first?
- A. Apply sequential compression devices bilaterally
- B. Initiate prescribed L-thyroxine replacement therapy
- C. Obtain prescribed calcium gluconate for tetany
- D. Prepare for emergency tracheotomy at the bedside
Correct answer: C
Rationale: The correct answer is C: Obtain prescribed calcium gluconate for tetany. Tingling sensations post-thyroidectomy may indicate hypocalcemia, a potential complication that requires prompt treatment with calcium gluconate to prevent tetany. Initiating L-thyroxine replacement therapy (choice B) is important but not the first priority in this situation. Applying sequential compression devices (choice A) is not indicated for tingling sensations and does not address the potential complication of hypocalcemia. Preparing for an emergency tracheotomy (choice D) is not warranted based on the client's symptoms of tingling sensations.
4. While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness of breath. Which action should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Assist the client back to the room
- C. Have the client sit down in the hall
- D. Obtain a 12-lead electrocardiogram
Correct answer: C
Rationale: Having the client sit down in the hallway is the first action the nurse should implement. This is crucial to prevent further strain on the heart and to provide a safer environment for assessment and potential emergency intervention. Administering sublingual nitroglycerin (Choice A) may be appropriate later but should not precede ensuring the client's immediate safety. Assisting the client back to the room (Choice B) may not be advisable if the client is experiencing chest tightness and shortness of breath. Obtaining a 12-lead electrocardiogram (Choice D) is important but would not be the initial action to address the client's immediate symptoms.
5. In a group therapy setting, one member is very demanding, repeatedly interrupting others and taking most of the group time. The nurse's best response would be:
- A. Will you briefly summarize your point because others need time as well?
- B. Your behavior is obnoxious and drains the group.
- C. I am so frustrated with your behavior.
- D. To ignore the behavior and allow him to vent
Correct answer: A
Rationale: In a group therapy setting, where each member should have the opportunity to participate, it is essential for the nurse to manage disruptive behavior assertively yet respectfully. Choice A is the best response as it addresses the issue of one member dominating the group time by asking them to summarize their point briefly, allowing others to contribute. Choice B is confrontational and may alienate the individual, hindering the therapeutic process. Choice C expresses personal frustration, which is not constructive in managing the situation. Choice D of ignoring the behavior is not effective as it allows the disruptive behavior to continue, impacting the group dynamics negatively.
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