HESI LPN
HESI PN Exit Exam Questions
Question 1 of 5
For an older postoperative client with the nursing diagnosis 'impaired mobility related to fear of falling,' which desired outcome best directs the nurse's actions for the client?
Correct Answer: C
Rationale: Encouraging the client to use self-affirmation statements is the most appropriate desired outcome in this scenario. By utilizing self-affirmation statements, the client can address their fears directly and build confidence, which can ultimately lead to a reduction in fear of falling. While ambulating with assistance (choice
A) is important, the focus here is on addressing the fear itself. Instructing the client in the use of a walker (choice
B) and placing a gait belt on the client (choice
D) are interventions that may be helpful but do not directly address the client's fear of falling.
Question 2 of 5
An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the PN?
Correct Answer: C
Rationale: In 90-90 traction, it is crucial to ensure that the weights are not touching the foot of the bed as this can disrupt the effective application of traction. This interference can hinder the proper alignment of the fractured femur and impede the healing process.
Therefore, this finding requires immediate action to prevent complications.
Choices A, B, and D are not directly related to the proper application of traction and do not pose a risk to the patient's treatment or well-being. No bowel movement for two days may indicate constipation but does not directly relate to the traction. Mother assisting the child in changing positions is a supportive action. The child being able to move the toes freely when tickled indicates neurological function, which is a positive sign.
Question 3 of 5
When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?
Correct Answer: C
Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (
Choice
A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (
Choice
B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (
Choice
D) is also important but comes after ensuring safe transportation and evacuation plans are in place.
Question 4 of 5
A client who is post-operative from a spinal fusion surgery reports a sudden onset of severe headache when sitting up. What is the nurse's priority action?
Correct Answer: B
Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.
Question 5 of 5
The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?
Correct Answer: D
Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern.
Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety.
Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP.
Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.