when a small fire breaks out in the kitchen of a long term care facility which task is most important for the pn to perform instead of assigning it to
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Nursing Elites

HESI LPN

HESI PN Exit Exam

1. During a fire incident in a long-term care facility's kitchen, which task is most crucial for the PN to perform instead of delegating to UAP?

Correct answer: C

Rationale: During a fire emergency, the most critical task for the PN is to identify the method for transporting and evacuating each resident. This task ensures a safe and organized evacuation plan, which is essential for everyone's safety. Delegating this responsibility to an unlicensed assistive personnel (UAP) may lead to errors or delays in the evacuation process. Closing doors to residents' rooms (Choice A) can help contain the fire but is not as urgent as planning the evacuation. While offering comfort and reassurance (Choice B) is important, it should not take precedence over ensuring a safe evacuation. Providing blankets (Choice D) is helpful but does not directly address the primary concern of safely evacuating residents.

2. What is the most common cause of hyperthyroidism?

Correct answer: A

Rationale: Corrected Rationale: Graves' disease is the most common cause of hyperthyroidism. It is characterized by an overactive thyroid gland due to autoantibodies stimulating the thyroid. Hashimoto's thyroiditis is actually a cause of hypothyroidism, not hyperthyroidism. Thyroid nodules and pituitary adenoma are not common causes of hyperthyroidism.

3. In obtaining an orthostatic vital sign measurement, what action should the nurse take first?

Correct answer: C

Rationale: The correct first action when obtaining an orthostatic vital sign measurement is to instruct the client to lie supine. This allows for establishing a baseline measurement of vital signs before any positional changes. Counting the client's radial pulse (Choice A) is a step that follows after the initial supine position to assess changes in pulse rate. Applying a blood pressure cuff (Choice B) and assisting the client to stand upright (Choice D) are actions that come later in the process after the baseline measurements are obtained in the supine position.

4. 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.

5. A client is recovering from a craniotomy and has a ventriculostomy in place. The nurse notices the drainage from the ventriculostomy is suddenly increasing. What should the nurse do first?

Correct answer: C

Rationale: A sudden increase in drainage from a ventriculostomy could indicate a serious complication such as increased intracranial pressure or hemorrhage. The priority action in this situation is to notify the healthcare provider immediately to ensure prompt evaluation and intervention. Increasing the head of the bed may be beneficial in some situations but is not the first action to take. Clamping the ventriculostomy tube is inappropriate as it can lead to increased intracranial pressure. Measuring the client's head circumference is not the priority when there is a sudden increase in ventriculostomy drainage.

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