HESI LPN
HESI PN Exit Exam 2024 Questions
Question 1 of 5
A child with glomerulonephritis is admitted in the acute edematous phase. Based on this diagnosis, which nursing intervention should the PN plan to include in the child's plan of care?
Correct Answer: C
Rationale: The correct answer is to measure blood pressure every 4 to 6 hours. In glomerulonephritis, monitoring blood pressure is crucial as hypertension is a common complication. This helps in assessing the child's condition and response to treatment. Choice A, recommending parents bring favorite snacks, is not related to managing glomerulonephritis. Choice B, encouraging ambulation daily to the playroom, may not be appropriate during the acute edematous phase when the child may be experiencing fluid overload. Choice D, offering a selection of fresh fruit for each meal, is not directly relevant to managing the complications of glomerulonephritis.
Question 2 of 5
A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?
Correct Answer: C
Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.
Question 3 of 5
A client is 48 hours post-op from a bowel resection and has not had a bowel movement. The client is complaining of abdominal pain and bloating. What is the nurse's best action?
Correct Answer: C
Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.
Question 4 of 5
A client is post-operative day one following a colostomy surgery. The nurse notices the stoma is dark purple. What is the most appropriate action?
Correct Answer: C
Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.
Question 5 of 5
A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?
Correct Answer: A
Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.