HESI LPN
HESI PN Exit Exam 2024 Questions
Question 1 of 5
The nurse and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the nurse implement?
Correct Answer: A
Rationale: The correct action for the nurse to implement is to demonstrate to the UAP how to approach the client from the client's left side. Approaching the client from the neglected side (left side) can help in retraining the brain and improving awareness of the affected side, which is crucial in the management of neglect syndrome. Choice B is incorrect as assessing the client's body for bruising is not directly related to managing neglect syndrome. Choice C is incorrect as observing the interaction between the client and family members does not address the specific intervention needed for neglect syndrome. Choice D is incorrect because protecting the client's left side when transferring to a chair does not actively involve retraining the brain and improving awareness of the neglected side, which is the primary goal in managing neglect syndrome.
Question 2 of 5
The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?
Correct Answer: C
Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.
Question 3 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 nurse?
Correct Answer: C
Rationale: The correct answer is C. In 90-90 traction, the weights should hang freely and not touch the foot of the bed to maintain proper traction and bone alignment. Option A is not necessarily a concern as bowel movements can be influenced by various factors, including diet changes and pain medication. Option B indicates good caregiver involvement, promoting comfort and preventing complications. Option D demonstrates neurovascular function, which is a positive finding. Therefore, the weights touching the foot of the bed is the finding that requires immediate attention to ensure the effectiveness of the traction.
Question 4 of 5
The nurse determines that a client with cirrhosis is experiencing peripheral neuropathy. What action should the nurse take?
Correct Answer: A
Rationale: Protecting the client's feet from injury is essential when managing peripheral neuropathy in a client with cirrhosis. Peripheral neuropathy can result in reduced sensation, increasing the risk of injury. Applying a heating pad or keeping the client's feet elevated would not address the primary concern of preventing injury. Assessing the feet and legs for jaundice is important for monitoring liver function, but it is not directly related to managing peripheral neuropathy in this case.
Question 5 of 5
An 8-year-old child is placed in 90-90 traction for a fractured femur. The nurse notices that the weights are touching the foot of the bed. What action should the nurse take?
Correct Answer: C
Rationale: The nurse should ensure that the weights in traction are not touching the foot of the bed. This is crucial to maintain proper alignment and effectiveness of the traction. When the weights touch the bed, it can compromise the traction's function and delay healing. Choices A, B, and D are incorrect as they do not address the issue of ensuring that the weights are not touching the bed, which is essential for the traction to work effectively.