HESI LPN
HESI PN Exit Exam 2023 Questions
Question 1 of 5
Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?
Correct Answer: C
Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (
Choice
A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (
Choice
B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (
Choice
D) is important but not the first priority when the client is experiencing unrelieved pain.
Question 2 of 5
Which of the following factors increases the risk of developing a pressure ulcer?
Correct Answer: C
Rationale: Immobility is a significant risk factor for pressure ulcers because it leads to prolonged pressure on specific areas of the body, reducing blood flow and leading to tissue breakdown.
Choices A, B, and D are incorrect. A high-protein diet can actually aid in wound healing and tissue repair. Frequent repositioning helps relieve pressure on bony prominences, reducing the risk of pressure ulcers. Active range of motion exercises can improve circulation and prevent muscle atrophy, thereby reducing the risk of pressure ulcers.
Question 3 of 5
A client post-splenectomy is at risk for infection. What is the most important preventive measure the nurse should emphasize during discharge teaching?
Correct Answer: C
Rationale: The correct answer is C: 'Wash hands frequently and practice good hygiene.' After a splenectomy, the client is at an increased risk of infection due to the role of the spleen in the immune system. Maintaining good hand hygiene, such as frequent handwashing, is crucial to prevent infections. While taking prescribed antibiotics as directed (
Choice
A) is important if prescribed, it is not the most crucial preventive measure in this scenario. Avoiding crowded places and sick people (
Choice
B) can help reduce the risk of exposure to pathogens but may not always be feasible. Keeping the surgical site clean and dry (
Choice
D) is important for wound care but is not the primary preventive measure to protect against infections in a post-splenectomy client.
Question 4 of 5
What is the first step in using an automated external defibrillator (AED) on a patient who has collapsed?
Correct Answer: B
Rationale: The correct answer is B: Turn on the AED and follow the voice prompts. This is the first step in using an AED as the device will guide you through the process of analyzing the heart rhythm and delivering a shock if necessary.
Choice A, applying the pads to the chest, comes after turning on the AED. Checking the patient's pulse (
Choice
C) is not necessary before using an AED as the device is specifically designed to assess the need for defibrillation. Ensuring the area is clear (
Choice
D) is important for safety but is not the initial step in using an AED.
Question 5 of 5
A client post-thoracotomy is complaining of severe pain with deep breathing and coughing. What should the nurse encourage the client to do to manage the pain and prevent respiratory complications?
Correct Answer: A
Rationale: Splinting the chest with a pillow helps manage pain during deep breathing and coughing, which is essential to prevent respiratory complications such as atelectasis or pneumonia after thoracic surgery. Holding a pillow against the chest while coughing (splinting) supports the incision site and reduces the pain associated with deep breathing and coughing. Encouraging shallow breaths (
Choice
B) can lead to respiratory complications due to inadequate lung expansion. Increasing pain medication (
Choice
C) should be done based on healthcare provider orders and not solely for this situation. Avoiding deep breathing exercises (
Choice
D) can worsen respiratory function and increase the risk of complications.