PN HESI Exit Exam

The correct answer is:

The lips and mucous membranes of a client with dark skin are dusky in color

Explanation for the Correct Answer:

In clients with dark skin tones, assessing for cyanosis (a bluish discoloration caused by low oxygen levels in the blood) can be challenging on the skin surface due to increased melanin. Instead, it is more reliable to examine areas with thinner skin and less pigmentation, such as the lips, oral mucosa, nail beds, and conjunctivae. A dusky, grayish, or bluish discoloration in these areas is a clear sign of cyanosis and indicates a need for immediate evaluation of the client's oxygenation status.

Why the Other Options Are Wrong:

Abnormal skin color changes in a client with dark skin cannot be determined 

This is false. Although more subtle, color changes such as cyanosis or pallor can still be observed in clients with dark skin by assessing the appropriate anatomical areas.

Blanching the soles of the feet in a client with dark skin reveals cyanosis

Blanching tests capillary refill time, which assesses circulation rather than oxygenation. It does not reliably indicate cyanosis and is not the best method for assessing oxygen status.

Cyanosis in a client with dark skin is seen in the sclera

The sclera is more appropriate for assessing jaundice, not cyanosis. Cyanosis is not typically evident in the sclera and should instead be assessed in mucous membranes and nail beds.

Correct Answer: Gravida 3 Para 3 who delivered vaginally 2 hours ago.

Explanation of the Correct Answer:

A postpartum woman who delivered 2 hours ago is in the immediate postpartum period, where close monitoring is essential. During this time, the primary concern is the possibility of complications such as excessive bleeding (postpartum hemorrhage), uterine atony, or shock. Immediate assessment is necessary to check uterine tone, the amount of bleeding, and signs of shock, which can develop rapidly. Given the short time since delivery, this client is at higher risk for these complications, and their condition must be monitored closely to ensure that the uterus is contracting and bleeding is controlled.

Why the Other Choices Are Incorrect:

Gravida 6 Para 5 who delivered vaginally 24 hours ago: Although this patient has delivered relatively recently, the 24-hour period since delivery places them beyond the immediate postpartum phase. While they still require monitoring for complications, the risk of acute postpartum hemorrhage or uterine atony is lower compared to someone who delivered just 2 hours ago. Therefore, this patient is not as urgent as the one who delivered more recently.

Gravida 1 Para 0 who is not having contractions: This client may need further evaluation, especially since lack of contractions could indicate an issue, but it is not as urgent as the situation in option C. It’s important to assess the firmness and contraction of the uterus, but postpartum hemorrhage risks are more acute in the first few hours after delivery. The absence of contractions can sometimes be a normal postpartum response, especially if the uterus is firm and well-contracted, but this situation doesn't present an immediate life-threatening risk compared to the client who delivered 2 hours ago.

Gravida 1 Para 2 who is preparing for discharge: This client is likely stable and no longer in the immediate postpartum period. They are preparing for discharge, which suggests that they are not experiencing any immediate risks. While they still need to be assessed before discharge, the situation is not as urgent as the client who delivered just 2 hours ago and is at a higher risk for acute postpartum complications.

Correct Answer:

Posterior tibialis artery

Dorsalis pedis artery

Explanation:

The posterior tibialis artery and the dorsalis pedis artery are the two primary sites for assessing pedal pulses, which provide important information about circulation to the feet and lower extremities. The posterior tibialis artery is found behind the medial malleolus, the prominent bone on the inner side of the ankle. It is a critical site for evaluating blood flow to the sole of the foot. The dorsalis pedis artery runs along the top of the foot between the first and second metatarsal bones and is readily palpable in many individuals. These pulse points are essential in assessing peripheral arterial disease and overall vascular status in the lower limbs.

Why Other Options Are Wrong:

Popliteal artery

This is incorrect because the popliteal artery is located behind the knee and is not considered a pedal pulse. Although it plays a major role in supplying blood to the lower leg and foot, it is a proximal artery and not used to directly assess circulation at the foot level. Palpation can also be difficult due to its deep location.

External femoral artery

This is incorrect because the external femoral artery is located in the groin and supplies blood to the entire lower extremity. It is considered a central or proximal pulse site rather than a distal one, and thus is not used to assess pedal circulation directly. It reflects overall limb perfusion but not specifically blood flow to the feet.

Radial artery

This is incorrect because the radial artery is located in the forearm near the wrist on the thumb side. It is used to evaluate upper extremity circulation and has no relevance to assessing pedal pulses. Using the radial artery to evaluate foot perfusion would not provide accurate or useful information.

The correct answer is:

Cut the bag opening to the measurement of the stoma size.

Explanation for the Correct Answer:

Cutting the ostomy bag opening to precisely match the stoma size is critical for achieving a secure seal and preventing stool leakage. An ill-fitting opening—either too large or too small—can result in stool escaping onto the peristomal skin, leading to irritation, breakdown, and infection. A snug fit also improves adhesion and comfort, ensuring that the bag remains in place during movement or output. Best practice includes using a stoma guide or measuring tool to trace the correct size before cutting the wafer or barrier. This principle is grounded in skin integrity preservation and infection prevention, key priorities in ostomy care.

Why the Other Options Are Wrong:

Place a 4X4 wick in the stoma opening:

This action is inappropriate and potentially harmful. The stoma is a functional opening meant to allow the passage of stool; inserting a wick could block output, causing pressure, leakage, or damage to the bowel. It also introduces a foreign object, increasing the risk of infection or trauma. This option demonstrates a misunderstanding of the stoma’s purpose and correct ostomy care protocols.

Apply a layer of zinc oxide ointment to the perimeter of the stoma:

Although zinc oxide protects skin from moisture, it creates a barrier that interferes with the adhesive seal of the ostomy appliance. This can compromise adhesion, leading to greater risk of leakage. Modern ostomy care favors skin barrier products designed specifically for compatibility with adhesive wafers, unlike general-purpose ointments.

Administer a PRN antidiarrheal agent:

While antidiarrheals can reduce output, they are not an appropriate first intervention for ostomy leakage. Furthermore, these medications require a prescription and clinical assessment, especially for clients with altered bowel anatomy. Relying on pharmacologic intervention without addressing the mechanical fit of the appliance fails to resolve the root cause of the leakage.

The correct answer is: Kidneys.

Explanation:

Retroperitoneal refers to organs that are located behind the peritoneum, which is the membrane that lines the abdominal cavity. The kidneys are located in the retroperitoneal space along with other organs like the adrenal glands, part of the pancreas, and the ascending and descending colon.

Why the other options are incorrect:

Testicles: The testicles are not retroperitoneal; they are located in the scrotum outside the peritoneal cavity.

Urinary bladder: The urinary bladder is located in the pelvic cavity, which is not considered retroperitoneal. It is located below the peritoneum.

Pancreas: The pancreas is partially retroperitoneal, meaning part of it lies behind the peritoneum, but it is not entirely retroperitoneal. Some parts of the pancreas, such as the tail, are located within the peritoneal cavity.

Summary:

The kidneys are the organs that are classified as retroperitoneal, meaning they lie behind the peritoneal cavity

Correct Answer: Syspnea who uses oxygen continuously.

Explanation:

When short-staffed, it is essential to prioritize clients based on the severity of their conditions and their immediate needs. In this case, a client experiencing dyspnea (difficulty breathing) who requires continuous oxygen is at immediate risk of respiratory compromise. Respiratory distress can escalate quickly and lead to life-threatening situations, so this client must be prioritized for assessment and intervention. Ensuring the client’s oxygenation is maintained is crucial to prevent further complications, including hypoxia or respiratory failure.

Why the Other Choices Are Incorrect:

Straight catheterization to be performed q6h:

While catheterization is an essential procedure for the client, it is more of a routine, scheduled task that can be managed by a UAP under supervision if the situation is stable. It does not require urgent attention in a situation where there are clients in more immediate need.

Frequent episodes of fecal incontinence:

Though frequent fecal incontinence is uncomfortable and requires care to prevent skin breakdown, it is not as urgent as a client experiencing breathing difficulties. This can be managed during regular rounds and does not require immediate action that could threaten the client's health.

Bolus feeding via PEG tube to be performed q4h:

While the feeding is essential for the client's nutrition, bolus feeding through a PEG tube is a routine task that can be planned and completed with supervision. It is not life-threatening, especially in the context of a short-staffed environment.

Correct Answer:

Encourage mobilization and ambulation

Explanation:

Early mobilization and ambulation are among the most effective nursing interventions to prevent complications in clients with pneumonia. Movement enhances lung expansion and helps prevent atelectasis, which can occur when alveoli collapse due to shallow breathing or mucus obstruction. Ambulation also stimulates coughing, promoting clearance of pulmonary secretions, and improves oxygenation and circulation. Mobilization has additional benefits, such as reducing the risk of deep vein thrombosis (DVT) and promoting overall physical recovery. As soon as the client is stable, nurses should encourage and assist with safe, gradual activity to support respiratory health and recovery.

Why Other Options Are Wrong:

Encourage energy conservation with complete bed rest

This is incorrect because prolonged bed rest can contribute to respiratory and circulatory complications. While conserving energy is important, complete immobility increases the risk of atelectasis, venous thromboembolism, and deconditioning. Unless the client is critically ill or unstable, early mobilization is preferred over strict bed rest in pneumonia management.

Provide humidified oxygen per nasal cannula

This is incorrect because although oxygen therapy can alleviate hypoxia, it does not address the root causes of pneumonia complications such as mucus retention or alveolar collapse. Humidified oxygen may ease breathing and improve comfort, but it is a supportive therapy, not a preventive intervention for complications like atelectasis.

Restrict PO and intravenous fluids

This is incorrect because adequate hydration is crucial for pneumonia patients. Fluids help thin mucus, facilitating mucociliary clearance and reducing the risk of airway obstruction. Unless the client has fluid restrictions due to a condition like heart failure, fluid restriction may worsen respiratory status by promoting mucus thickening and retention.

The correct answer is:

Determine if the client has any allergies to shellfish.

Explanation for the correct answer:

An Intravenous Pyelogram (IVP) is a diagnostic imaging procedure that uses an iodine-based contrast dye to visualize the urinary tract. A critical pre-procedural assessment is to determine whether the client has an allergy to shellfish, as individuals with shellfish allergies may also react to iodine-containing contrast media. Identifying this risk helps prevent potentially severe allergic reactions, such as anaphylaxis, during or after the administration of the dye.

Why the other options are incorrect:

Inform the client that an IV dye will be administered before the IVP:

While it's important to provide procedural information, this step does not address immediate safety concerns. Identifying allergies that could cause life-threatening reactions takes precedence over client education in this context.

Explain that dizziness may occur when the dye is given:

Side effects like dizziness or a warm sensation may occur, but these are generally mild and transient. The potential for a serious allergic reaction is a greater concern and must be addressed first.

Administer a bowel prep the evening before the procedure:

Although bowel preparation might be part of the protocol for certain imaging procedures, it is not the top priority for IVP preparation. The foremost concern is screening for allergies to contrast agents, especially iodine-based ones.