PN Hesi Exit Exam.
1) The LPN/LVN is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an
... [Show More] 8 pound 10 ounce infant. What intervention has the highest priority?
A. Administer Prescribed stool softener
B. Administer prescribed PRN sleep medications.
C. Encourage breastfeeding to promote uterine involution
D. Encourage use of prescribed analgesic perineal sprays.
Correct Answer: A. Administer Prescribed stool softener
2) The LPN/LVN is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area.
A. Duodenum
B. Gastric Pylorus
C. Liver
D. Spleen
Correct Answer: C. Liver
3) A client comes to the antepartal clinic and tells the LPN/LVN that she is 6 weeks pregnant. Which sign is she most likely to report?
A. Decreased sexual libido
B. Amenorrhea
C. Quickening
D. Nocturia
Correct Answer: B. Amenorrhea
4) A client's daughter phones the charge nurse to report that the night LPN/ LVN did not provide good care for her mother. What response should the nurse make?
A. Ask for a description of what happened during the night
B. Tell the daughter to talk to the unit's nurse manager
C. Reassure the daughter that the mother will get better care.
D. Explain that all the staff are doing the best they can.
Correct Answer: A. Ask for a description of what happened during the night
5) A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage?
A. Autonomy vs. Shame and doubt.
B. Industry vs. Inferiority
C. intiative vs. Guilt
D. Trust vs. Mistrust
Correct Answer: A. Autonomy vs. Shame and doubt.
6) Which action should the LPN/LVN implement in caring for a client following an electroencephalogram (EEG)?
A. Monitor the client's vital signs q4h
B. Assess for sensation in the client's lower extremities
C. Instruct the client to maintain bed rest for eight hours
D. Wash any paste from the client's hair and scalp
Correct Answer: D. Wash any paste from the client's hair and scalp
7) The LPN/LVN is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus?
A. Encourage the client to eat foods high in protein
B. Assess the client with daily range of motion exercises
C. Teach the family how to perform sterile wound care
D. Ensure the IV fluids are administered as prescribed
Correct Answer: A. Encourage the client to eat foods high in protein
8) What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space?
A. Filtration
B. Diffusion
C. Osmosis
D. Active transport
Correct Answer: C. Osmosis
9) The LPN/LVN is taking blood pressure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position?
A. Slightly above the level of the heart
B. At the level of the heart
C. At the level of comfort for the client
D. Below the level of the heart
Correct Answer: B. At the level of the heart
10) What are the final parameters that produce blood pressure? (select all that apply)
A. Heart rate
B. Stroke volume
C. Peripheral resistance
D. Neuroendocring hormones
E. Muscle tone
Correct Answer:
A. Heart rate
B. Stroke volume
C. Peripheral resistance
11) A client begins an antidepressant drug during the second day of
hospitalization. Which assessment is most important for the LPN/LVN to include in this client's plan of care while the client is taking the antidepressant?
A. Appetite
B. Mood
C. Withdrawal
D. Energy level
Correct Answer: B. Mood
12) Based on the documentation in the medical record, which action should the LPN/LVN implement next?
A. Give the rubella vaccine subcutaneously
B. Observe the mother breastfeeding her infant
C. Call the nursery for the infant's blood type result
D. Administer Vicodin one tablet for pain
Correct Answer: Give the rubella vaccine subcutaneously
13) A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the LPN/LVN implement to prevent complications associated with Pneumonia?
A. Encourage mobilization and ambulation
B. Encourage energy conservation with complete bed rest
C. Provide humidified oxygen per nasal cannula
D. Restrict PO and intravenous fluids
Correct Answer: Enourage mobilization and ambulation
14) The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only)
Correct Answer:15
15) Which nursing activity is within the scope of practice for the practical nurse?
A. Complete an admission assessment in the normal newborn nursery.
B. Discontinue a central venous catheter that has become dislodged
C. Observe a client rotate the subcutaneous site for an insulin pump
D. Monitor a continous narcotic epidural for a postoperative client
Correct Answer: C. Observe a client rotate the subcutaneous site for an insulin pump
16) After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel?
A. Identify the need for additional supplies to provide an extra dressing change
B. Provide perianal care and collect clean linens for the dressing change
C. Document the diarrhea that necessitates an additional dressing change
D. Position the client for access to the decubiti sties and remove dressings
Correct Answer: B. Provide perianal care and collect clean linens for the dressing change
17) The LPN/LVN is planning to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration in the order from fastest to slowest rate of absorption.
Subcutaneous Intravenous Intramuscular Sublingual Oral
Correct Answer: Intravenous, sublingual, intramuscular, subcutaneous,
oral.
18) A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the LPN/LVN assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene?
A. Offer to call the social worker to discuss the possibility of abortion
B. Reassure the client that the infertility specialist can help
C. Express sorrow for the client's grief and offer to sit with her
D. Chart the vital signs and amount of vaginal bleeding
Correct Answer: Express sorrow for the client's grief and offer to sit with her
19) A terminally ill male client and his family are requesting hospice care after discharge from the hospital and ask the LPN/LVN to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care?
A. Enhance symptom management to improve end of life quality
B. facilitates assisted suicide with the client's consent
C. Offers ways to postpone the death experience at home
D. Provide training for family members to care for the client.
Correct Answer: A. Enhance symptom management to improve end of life quality
20) The LPN/LVN observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take?
A. Advise the wife to shave against the hair growth
B. Teach the wife to keep the skin loose to avoid cuts
C. Encourage the wife to continue shaving her husband
D. Demonstrate the correct procedure to the wife
Correct Answer: C. Encourage the wife to continue shaving her husband
21) To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply)
A. Posterior tibialis artery
B. Politeal artery
C. External femoral artery
D. Dorsalis pedis artery E Radial artery
Correct Answer: A. Posterior tibialis artery, D. Dorsalis pedis artery
22) The LPN/LVN is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain?
A. Smokes one pack of cigarettes daily
B. Drinks two beers daily
C. Works in a job that requires exposure to the sun
D. Eats while lying in bed
Correct Answer: A. Smokes one pack of cigarettes daily
23) The LPN/LVN is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catheterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take?
A. Stand the client to void and run tap water within hearing distance before catheterizing the client.
B. Straight catheterize and if the residual using volume is greater than 100 mL, clamp catheter
C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period.
D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
Correct Answer: D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon.
24) A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects?
A. Moon face, Slow wound healing, muscle wasting sodium and water retention
B. Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbital edema
D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension
Correct Answer: A. Moon face, Slow wound healing, muscle wasting sodium and water retention
25) The cervix is the opening into the uterine cavity. What is its function in reproduction?
A. Accepts and interprets signals of sexual stimuli
B. Secretes mucus to facilitate sperm transport
C. Serves as the site for union of ovum and sperm
D. Receives the penis during intercourse
Correct Answer: B. Secretes mucus to facilitate sperm transport
26) The LPN/LVN is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection?
A. 17-year-old who is sexually active simultaneously with numerous partners
B. 34-year old homosexual who is in a monogamous relationship
C. 30-year-old cocaine user who inhales and smokes drugs
D. 45-year-old who has received two blood transfusions in the past 6 months
Correct Answer:A. 17-year-old who is sexually active simultaneously with numerous partners
27) The LPN/LVN is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate?
A. Conversion of irregular heart rate to regular heart rhythm
B. Pulse oximetry readings within normal range during activity
C. Peripheral pulse points with adequate capillary refill
D. Increase exercise tolerance without shortness of breath
Correct Answer: A. Conversion of irregular heart rate to regular heart rhythm
28) An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide?
A. Use an over the counter stool softener when needed
B. Eat a high protein diet
C Increase the fluid intake in your diet
D. Decrease the fat content in your diet
Correct Answer: C. Increase the fluid intake in your diet
29) The LPN/LVN is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client?
A. Abnormal skin color changes in a client with dark skin cannot be determined
B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
C. The lips and mucus membranes of a client with dark skin are dusky in color
D. Cyanosis in a client with dark skin is seen in the sclera
Correct Answer: C. The lips and mucus membranes of a client with dark skin are dusky in color
30) When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes uring flow into the tubing. What action is taken next?
A. Document the color and clarity of the urine
B. Insert the catheter an additional inch
C. Ask the client to breathe deeply and slowly exhale
D. Inflate the balloon with 5mL of sterile water
Correct Answer: B. Insert the catheter an additional inch
31) A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality?
A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain
B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
C. An infusion of medication in the spinal canal will block pain perception
D. The discharge of electricity will distract the client's focus on the pain
Correct Answer: B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
32) Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority?
A. Application of topical antibacterial cream
B. Use of careful hand washing technique
C. Administration of plasma expanders
D. Limiting visitors to the burned client.
Correct Answer: B. Use of careful hand washing technique
33) The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? [Show Less]