HESI LPN- Entrance Exam

HESI LPN- Entrance Exam 2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limits and her sugar is 325 mg/dL. what intervention should the nurse implement first? - ✔-administer regular insulin per sliding scale A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period? - ✔-nipple feedings with glucose water a 3 year-old admitted with fever of unknown (FUO) has begun vomiting in the past half hour. The child's temp. is 101.8F, and the last does of antipyretic medication was given 5 hours ago. the child has prescriptions of acetaminophen (Tylenol) 160 mg per 5 mL elixir or 16o mg suppositories PRN fever or pain. what action should the nurse take at this time? - ✔-make the child NPO and hold all mediations until the vomiting has stopped.

4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. what action should the nurse take? - ✔-give the client crackers and milk a 6-month child with bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates the nurse that he is experiencing respiratory distress? - ✔-A high pitched cry.

An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast.

Which cereal should the nurse provide? - ✔-rice total number of confirmed pregnancies regardless of the outcome - ✔-Gravida number of births after 20 weeks - ✔-Para pregnant for the first time - ✔-primigravida 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 nurse assess the vital signs and vaginal bleeding. the client begins to cry softly. how should the nurse intervene? - ✔express sorrow for the clients grief and offer to sit with her.

A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? - ✔-they can have intercourse when the episiotomy is healed and the lochial flow has stopped

36 hours after delivery, the nurse determines a clients fundus is just above the umbilicus and displaced to the right of midline. what action should the nurse take first? ✔-palpate the bladder for distention a 60 year old client with cancer of the liver is in hepatic coma and unresponsive. what should the nurse say to family members were inquiring about the condition of their loved one? - ✔-"Your loved ones condition is very critical, and there has been no response in the last 24 hours" a 67 year old woman who lives alone tripped on a rug in her home and fractured her right hip. the nurse knows that which predisposing factor contributes to the occurrence of hip fractures among elderly women. - ✔-osteoporosis resulting from hormonal changes. a 75 year old male client with Alzheimer disease is admitted to an extended care facility. what intervention should the nurse include into the his clients Nursing care plan? - ✔plan to have the same nursing staff provide care for the client whenever possible. an 82-year old client is admitted to the hospital with a fractured right hip. following surgical repair, a footboard is placed at the clients feet. what is the reason the nurse will offer concerning the footboard? - ✔-footboard is used to prevent foot drop.

An adult female client is admitted to the psychiatric unit with diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement? - ✔-ask the client if she has had any recent thoughts of harming herself. an adult male client tells the nurse that he believes someone is trying to obtain his cpu records, which his wife reports are recreational in nature. the client insist that an elaborate alarm system needs to be installed in his home. the nurse knows that this client is exhibiting which signs or symptoms? - ✔-delusions of persecution After a change of shift report, the nurse makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the nurse? - ✔-A. A client who is having bright red drainage from the rectum following a colonoscopy with a polyp removal After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-poundweight loss from the pre-dialysis weight. The client reports feeling weak and fatigued. What action should the nurse take next? - ✔-A. Measure the client's blood pressure

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? - ✔-B. Provide perianal care and collect clean linens for the dressing change After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is..... - ✔-D. Trembling and has a glucose level of 50 mg/dL An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first time. What is the best intervention for the nurse to implement? - ✔-B. Keep the catheter intact and assist the client with a shower At 7AM, a Diabetic client is conscious with a serum glucose level of 50mg/dL. To manage this client's care effectively, what should the nurse administer? - ✔-A. Orange juice Augmentin (amoxicillin/clavulante) 500mg suspension is prescribed for an older adult client who has trouble swallowing . The suspension is available in 125mg/5mL solution.

How many ml should the client receive? (enter the numberic value only) - ✔-20 Based on the documentation in the medical record, which action should the nurse implement next? - ✔-A. Give the rubella vaccine subcutaneously Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? - ✔-B. Use of careful hand washing technique Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary incontinence? ✔-A. Maintain standard precautions The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional conflict related to concerns about mechanical ventilation." When assigned to care for this client, what intervention should the nurse implement based on this diagnosis ? - ✔-D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation The cervix is the opening into the uterine cavity. What is its function in reproduction? ✔-B. Secretes mucus to facilitate sperm transport The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first? - ✔-D. Consult with the charge nurse about the catheter

A child with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse administer the meter-dosed inhaler (MDI) puff of bronchodilator relative to postural drainage treatments? - ✔-After postural drainage A client asks the nurse to explain the location of the prostate gland. What is the best response? - ✔-A. Close the rectal wall the prostate gland sits behind the symphysis pubis extending around thebeginning of the urethra A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer? - ✔-C. 0.25 A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant? - ✔-Mood a client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. which sign is the most likely to report? - ✔-amenorrhea A client complains of kidney pain. The nurse understands that the kidneys are located where? - ✔-A. On the retroperitoneal posterior abdominal wall at the costovertebral angle 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? - ✔-B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take? - ✔C. Administer the aspirin with a full glass of water or a small snack A client has a prescription for lorazepam (ativan) 1 mg for anxiety. The medication is supplied as 0.5mg tablets. How many tablets should the client take? (enter numeric value only. - ✔-2 A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia? - ✔A. Encourage mobilization and ambulation

A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA).

The nurse anticipates implementing care for which client problem? - ✔-B. Altered breathing patterns A Client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture? - ✔-A. The neck extended backward using a rolled towel behind the neck A client is admitted to the rehabilitation unit after a Thrombotic Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive aphasia. What intervention should the nurse implement to communicate with the client? - ✔-D. Dysphagia precautions A client is admitted with a fever of undermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first? ✔-B. Check the client's vital signs and pain scale A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of tuberculosis (TB)? - ✔-A. Proper disposal of tissues when coughing A client is complaining of muscle fatigue in the lower extremities. What is the physiological cause of muscle fatigue? - ✔-A. The depletion of glycogen and energy stores A client is diagnosed with Clostridium Difficile (CDIFF). What action should the nurse implement to prevent the spread of the organism? - ✔-B. Don non-sterile gloves when performing direct care A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer? - ✔-A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack A client is having Radical Mastectomy. What is the position of choice during the immediate postoperative period? - ✔-C. Semi-Fowler's position with the arm on the operative side elevated A client is receiving 0.5 grams of a prescription medication that is dispensed as 500 mg/5mL. How many ml should the PN administer? (enter the numeric value only. If rounding is required, round to the nearest tenth.) - ✔-5 A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushioned side effects? - ✔-A. Moon face, Slow wound healing, muscle wasting sodium and water retention

A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the client to manifest in response to the administration of this drug during an acute anginal episode? - ✔-B. Cessation of acute chest pain A client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the nurse to include in this client's record? ✔-A. Pedal pulses, pallor, pain, paresthesia or paralysis A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrhaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what action? - ✔-C. Blowing forcefully into the mouthpiece A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? - ✔-C. Determine respiratory status and apply a pulse oximeter A client receives a new prescription for the angiotensin II receptor antagonist losartan (Cozaar). Which client instruction should the nurse encourage this client to follow? - ✔A. Move slowly when getting up to prevent sudden dizziness A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? - ✔-B. Longitudinally from the right forehead to the right cheek A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression devise (SCD) to both lower extremities. (BLE). What action is important when turning the client to a lateral position? - ✔-D. Observe the SCDs continue to inflate and deflate when the client is turned A client returns to the unit following a cardiac catheterization with a Femoral artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return? - ✔-B. Pedal pulses A client's chief complaint is being able to swallow only small bites of solid food and liquid's for the last 3months. The nurse should assess the client for what additional information? - ✔-A. History of alcohol and tobacco use A client's daughter phones the charge nurse to report that the night nurse 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 A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours

the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? - ✔-B. Change the Pleur-Evac system and re-assess output in the empty chamber A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first? - ✔-D. Check the client's dorsalis pedis and posterior tibialis pulse point A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what interventions should the nurse implement? - ✔-D. Maintain a quiet calm darkened enviornment A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan? - ✔-A. Drink 3 quarts of water daily During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not rising. What action should the nurse take first? - ✔-A. Reposition the head to ensure an open airway During immediate postoperative period, which condition has the highest priority when planning Nursing care? - ✔-B. Respiratory obstruction During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery? - ✔-A. "Deep breathing exercises using spirometer will help prevent postoperative complications."

During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take? - ✔-D. Record the findings and report the symptoms to the charge nurse During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse? - ✔-B. Reposition the oximeter clip An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and then tells the nurse, "I just don't feel right" Which initial action should the nurse take? - ✔-C. Give 4 ounces of apple juice An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath

sounds frequently. What other intervention should the nurse implement related to the client's decreased vital capacity? - ✔-A. Evaluate pulse oxygen saturation An elderly client is admitted for evaluation of Alzheimer's disease. At 2AM, the nurse finds the client trying to open the emergency door. What is the most appropriate response for the nurse to make in this situation? - ✔-A. "This is the emergency door.

Are you looking for the bathroom?"

An elderly female client tells the nurse that she does not do regular Breast Self Examinations (BSE) because she is too old. The nurse's response to the client is based on what information? - ✔-A. The incidence of breast cancer increases with age 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? - ✔-C Increase the fluid intake in your diet An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? - ✔C. The client will ambulate with assistance q4h A female client complains to the nurse about being admitted to a semi-private room and expresses her displeasure because she requested a private room prior to admission.

What response is best for the nurse to provide this client? - ✔-C. Your healthcare provider must provide a written request to get you a private room A female client is being prepared for a speculum exam. In which position should the nurse place the client? - ✔-C. Lithotomy A female client with no family history of Breast Cancer (BA) asks the nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question? - ✔-C. Breastfeeding history The first day after a cesarean section (C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take? - ✔C. Check fundal consistency and continue to monitor the lochial flow amount Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately? - ✔C. I've been feeling so light headed Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement? - ✔-C. Outline the area with ink and check it q15 minutes to see if the area has increased

The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number) - ✔-75mL X 15gtt/mL = 38 The healthcare provider prescribes erythromycin (ilosone) 300 mg PO QID. The medication label reads, "ilosone 100mg/5mL" How many mL should the nurse administer at each does? (Enter the numeric value only) - ✔-15 The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news? - ✔-C. Listen to the family's reactions and reflect and their fears and concerns The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throws it across the room and curses loudly. What action should the nurse implement? - ✔-D. Describe other types of medication containers that are available A hospitalized 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.

In assisting a client perform pursed lip breathing, the nurse should ensure that the client performs which action? - ✔-A. Inhale through the nose with the mouth shut and exhale through pursed lips In assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? - ✔-B. Re-instruct the client in coughing techniques to obtain another specimen In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client? - ✔-A. Empty and measure the drainage in the suction drainage device In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? - ✔-C. Count the apical pulse rate for sixty seconds

In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is... - ✔-C. a 32-yearold whose mother had breast cancer In obtaining an orthostatic vital sign measurement, what action should the nurse take first? - ✔-C. Instruct the client to lie supine In preparing a client for a lumbar puncture, what action should the nurse implement? ✔-C. Teach the client to cough and deep breathing exercises A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention will the nurse implement first?

- ✔-B. Determine the amount of water and exact time it was taken A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choice are cocaine and heroin. What is the greatest health risk for this client? - ✔-D. Glaucoma A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine.

He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse implement? - ✔-A. Offer the client a full glass of water A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? - ✔-D. Encourage the client's wife to express concerns about making the decision A male client with Hypercholesterolemia is being discharged with a new prescription for simvastatin (Zocor). The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond? - ✔-D. Confirm that the client correctly understands the need to monitor liver function regularly A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take? - ✔-D. Offer a hot meal a clean bed and a sleeping pill 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? - ✔-D. The mother refuses to answer questions about family history A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT

feedings? - ✔-A. Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide? - ✔-D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection A new mother is at the clinic with her 4-week old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2months of age. - ✔-B. Consistently returns smiles to mother The nurse assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepare for which treatment? - ✔-. Cold packs to the perineum The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspirations. To ensure that the task is safely delegated what action should the nurse implement? - ✔-C. Observe the UAP's ability to implement precautions during feed The nurse assumes care of a client who was admitted earlier in the day for a scheduled Hysterectomy in the morning. Which recorded assessment data obtained by the admitting registered nurse is objective? (Select all that apply). - ✔-A. Anemia, D. Orthostatic hypotension The nurse assess a client receiving a hypertonic full strength tube feeding that is infusing continuous at 50 mL/hr. Which finding is most important for the nurse to report to the charge nurse? - ✔-C. Report of increased hunger A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should action should the nurse take? - ✔-C. Supervise the UAP after reviewing the protocol The nurse can also refer to the external ear as what other known name... - ✔-A. Pinna