HESI LPN
HESI PN Exit Exam
1. When teaching a patient about the side effects of a new medication, which teaching method is most effective?
- A. Providing a written pamphlet
- B. Giving verbal instructions only
- C. Demonstrating how to take the medication
- D. Using a combination of verbal, written, and demonstration methods
Correct answer: D
Rationale: The most effective teaching method when educating a patient about the side effects of a new medication is to use a combination of verbal, written, and demonstration methods. This comprehensive approach ensures that the patient receives information through multiple channels, catering to different learning styles. Verbal instructions allow for direct communication, written materials provide a reference for the patient to review later, and demonstrations offer a visual aid that can enhance understanding. Providing a combination of these methods increases the likelihood of the patient retaining and comprehending the information effectively. Choices A, B, and C are less effective as they do not encompass the benefits of utilizing multiple teaching modalities.
2. A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?
- A. Document the finding as normal.
- B. Notify the healthcare provider immediately.
- C. Decrease the suction on the T-tube.
- D. Flush the T-tube with saline to ensure patency.
Correct answer: A
Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.
3. When preparing to administer a medication through a nasogastric (NG) tube, what is the first action the nurse should take?
- A. Check the placement of the NG tube
- B. Flush the tube with saline
- C. Position the client in a semi-Fowler's position
- D. Administer the medication slowly
Correct answer: A
Rationale: The correct first action when preparing to administer a medication through a nasogastric (NG) tube is to check the placement of the NG tube. This step is essential to ensure that the tube is correctly positioned in the stomach and not in the lungs, preventing potential complications. Flushing the tube with saline may be required, but it should follow the verification of tube placement. Positioning the client in a semi-Fowler's position is necessary for comfort during the procedure but is not the initial step. Administering the medication can only be done safely after confirming the correct placement of the NG tube.
4. Which laboratory value is most important to monitor for a patient receiving heparin therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. International normalized ratio (INR)
Correct answer: C
Rationale: The correct answer is C, Partial thromboplastin time (PTT). PTT is monitored to assess the therapeutic effect of heparin therapy. It helps ensure that the heparin levels are within the desired range to prevent either clotting or excessive bleeding. Platelet count (A) is important but does not directly assess heparin's therapeutic effect. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor patients on warfarin, not heparin therapy.
5. An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan?
- A. Plan to have the same nursing staff provide care for the client whenever possible
- B. Describe the activities available to residents and encourage him to choose the ones he prefers
- C. Encourage the client to remain on the unit for three weeks until he is oriented to his new surroundings
- D. Introduce the client to the nursing staff and other residents as soon as possible
Correct answer: A
Rationale: The correct intervention for a client with Alzheimer's disease in an extended care facility is to plan to have the same nursing staff provide care whenever possible. Consistency in caregivers helps reduce confusion and anxiety in clients with Alzheimer’s disease, promoting a stable and supportive environment for the client. Choice B is incorrect as it focuses on activities rather than the consistency of caregivers. Choice C is incorrect as it suggests isolating the client, which can lead to increased confusion and distress. Choice D is incorrect as introducing the client to new people immediately can be overwhelming and may exacerbate their symptoms.
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