HESI LPN
HESI PN Exit Exam 2024 Questions
Question 1 of 5
While caring for a client with a new tracheostomy, the nurse notices that the client is attempting to speak but is unable to. What should the nurse explain to the client regarding their inability to speak?
Correct Answer: B
Rationale: The correct answer is B. The tracheostomy tube bypasses the vocal cords, preventing air from reaching them, which is necessary for speech. This makes speaking difficult but not impossible. Removing the tracheostomy tube does not automatically restore the ability to speak (choice C). While a speaking valve can be added later to allow speech, initially, the tracheostomy tube itself hinders air from reaching the vocal cords, making speech difficult (choice D is incorrect). Choice A is incorrect as the tracheostomy tube does not block the vocal cords directly; instead, it prevents air from reaching them.
Question 2 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 3 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 4 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.
Question 5 of 5
A client with a chest tube following a pneumothorax is concerned about the continuous bubbling in the water seal chamber. What should the nurse explain to the client?
Correct Answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube system indicates an air leak. An air leak can prevent the lung from fully re-expanding and may lead to complications like a recurrent pneumothorax. Therefore, it is crucial to investigate and address the air leak promptly. Choices B and C are incorrect because continuous bubbling is not normal and does not indicate lung expansion. Choice D is incorrect because the nurse should first assess and then report the issue to the healthcare provider.