PN HESI Exit Exam

Correct Answer:

Wash any paste from the client's hair and scalp

Explanation:

After an electroencephalogram (EEG), one of the most important post-procedure actions is to clean any remaining conductive paste from the client's scalp and hair. The EEG procedure involves placing electrodes on the scalp with a conductive paste or gel to measure brain electrical activity. This paste can dry and become sticky, so it is essential to remove it to prevent discomfort, maintain hygiene, and avoid potential scalp irritation. Properly washing the paste ensures the client's comfort and promotes good post-procedure care.

Why Other Options Are Wrong:Monitor the client's vital signs q4h

This is incorrect because an EEG is a non-invasive procedure that does not typically lead to any significant physiological changes requiring frequent vital sign monitoring. Unless there are specific concerns or underlying medical conditions, routine monitoring of vital signs every four hours is unnecessary. The post-EEG care primarily focuses on the client’s comfort rather than intensive physiological monitoring.

Assess for sensation in the client's lower extremities

This is incorrect because an EEG only measures electrical activity in the brain and does not affect motor or sensory function. The procedure does not involve any physical manipulation of the body or require the assessment of sensation in the lower extremities. There is no risk of numbness or weakness in the legs after the procedure, so this assessment is irrelevant.

Instruct the client to maintain bed rest for eight hours

This is incorrect because bed rest is not required after an EEG. The procedure is non-invasive and does not typically affect the client’s ability to resume normal activities. If sedation was used, a short period of observation may be needed, but eight hours of bed rest is excessive and unnecessary for routine post-EEG care.

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.

The correct answer is:

Neurological integrity.

Explanation for the correct answer:

The Moro reflex, also known as the startle reflex, is an important indicator of neurological integrity in newborns. This reflex is present at birth and involves the infant's response to a sudden loss of support or loud noise, where the baby extends their arms and legs and then rapidly brings them back toward the body, as if embracing. The presence of this reflex suggests that the infant's central nervous system (CNS), including the brain and spinal cord, is functioning properly. If the reflex is absent or asymmetric, it may indicate potential neurological problems.

Why the other options are wrong:

The Moro reflex does not provide any information regarding renal function. Renal function is assessed through laboratory tests, such as measuring urine output or serum creatinine levels, rather than the Moro reflex.

Thermoregulation, or the ability to maintain a stable internal temperature, is not assessed by the Moro reflex. It is typically evaluated by monitoring the infant’s body temperature and ensuring they are appropriately dressed or kept warm after birth.

The Moro reflex does not assess the infant's respiratory status. Respiratory adequacy is evaluated through the infant's breathing patterns, oxygen saturation levels, and overall respiratory effort, not by the Moro reflex.

The correct answer is:

Raise the bed to ensure the drainage bag remains off the floor.

Explanation for the Correct Answer:

Proper catheter care involves maintaining the urinary drainage bag below the level of the bladder and off the floor at all times. This position uses gravity to facilitate continuous urine drainage while preventing urinary reflux, which can lead to bladder infections or kidney damage. Additionally, keeping the bag off the floor reduces the risk of contamination from environmental surfaces and minimizes the chance of introducing pathogens into the urinary tract. According to infection control standards, the floor is considered a high-contamination area. Therefore, adjusting the bed to elevate the drainage bag is a critical step in preventing catheter-associated urinary tract infections (CAUTIs) and promoting client safety.

Why the Other Options Are Wrong:

Attach the drainage bag to the side rail instead of the bed frame:

Attaching the drainage bag to the side rail is incorrect and unsafe. Side rails move independently when raised or lowered, which could pull on the catheter tubing, leading to urethral trauma, dislodgement, or urinary retention. The bed frame, which remains stationary, is the correct location to secure the drainage bag and maintain proper alignment and function of the catheter system.

Observe the appearance of the urine in the drainage tubing:

While monitoring urine color, clarity, and volume is an important part of routine assessment, it does not address the immediate infection risk posed by a drainage bag resting on the floor. Observing urine does not correct the improper positioning of the bag, which can allow backflow of contaminated urine and increase the risk for CAUTIs.

Secure the tubing to the client's gown instead of his abdomen:

Securing catheter tubing to a client’s gown is inappropriate because the gown moves with client repositioning or ambulation, increasing the risk of accidental pulling or catheter displacement. The tubing should be secured to the client's abdomen or upper thigh, depending on gender and positioning, to provide stable support, prevent urethral irritation, and reduce the risk of injury or infection.

Correct Answer:

Moon face, slow wound healing, muscle wasting, sodium and water retention

Explanation:

The listed symptoms—moon face, slow wound healing, muscle wasting, and sodium and water retention—are classic signs of Cushingoid effects, which are caused by prolonged use of corticosteroids like dexamethasone. These symptoms are characteristic of Cushing’s syndrome, which results from an excess of glucocorticoids, either due to endogenous overproduction (Cushing’s disease) or exogenous administration (such as with corticosteroid therapy).

Moon face is due to fat redistribution, which is commonly seen in individuals receiving corticosteroids, giving their face a rounded, puffy appearance.

Slow wound healing occurs because glucocorticoids impair protein metabolism and immune function, hindering the body’s ability to repair tissue efficiently.

Muscle wasting results from the catabolic effects of corticosteroids on skeletal muscle, leading to a loss of muscle mass over time.

Sodium and water retention is caused by the mineralocorticoid-like effects of corticosteroids, which lead to increased retention of sodium and water, contributing to edema and hypertension.

These symptoms should be closely monitored when corticosteroid therapy is prescribed, as they can significantly affect the patient’s quality of life.

Why Other Options Are Wrong:

Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor

This is incorrect because these symptoms are characteristic of hyperthyroidism, specifically Graves' disease, and not a result of corticosteroid use. While dexamethasone is a potent corticosteroid, it does not cause the hypermetabolic symptoms associated with thyroid disorders. Dexamethasone can, in fact, cause hypertension but through different mechanisms—primarily through sodium retention and water retention, not through metabolic acceleration like in hyperthyroidism.

Bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema

This is incorrect because these symptoms point toward hypothyroidism, particularly myxedema, which is characterized by slow metabolism. While weight gain may occur with corticosteroids, dexamethasone does not typically cause bradycardia, cold intolerance, or myxedema. The drug’s effects are related to the redistribution of body fat, fluid retention, and muscle wasting, not the slowing down of metabolic processes seen in hypothyroidism.

Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension

This is incorrect because these are signs of Addison’s disease (adrenal insufficiency), which occurs when the adrenal glands do not produce enough corticosteroids. Dexamethasone, being a synthetic corticosteroid, has the opposite effects: it promotes sodium retention, decreases potassium levels, and tends to cause hypertension rather than hypotension. These findings would not be seen in someone taking dexamethasone.

Correct Answer: Sunken fontanels

Why this is Correct:

Sunken fontanels are a classic sign of dehydration in infants, which can result from persistent vomiting and an inability to retain fluids or nutrients. At 4 weeks old, a baby relies entirely on frequent, successful feedings for hydration and nutrition. If vomiting occurs after every feeding, it may lead to fluid loss and inadequate intake, both of which contribute to dehydration. The fontanels (soft spots on the baby’s head) provide a visible indicator of this fluid deficit. Recognizing sunken fontanels allows for prompt intervention before dehydration progresses to a more serious condition.

Why Others are Wrong:

Absent Moro reflex: This could indicate neurological impairment but is not directly tied to nutritional status or hydration. It is a concerning finding in itself, but not the most relevant sign when evaluating for inadequate nutrition due to vomiting.

Hypoactive bowel sounds: These are more indicative of decreased gastrointestinal activity or obstruction, not a primary sign of dehydration or poor feeding. They do not clearly indicate a nutritional deficit in this context.

Tachypnea: An increased respiratory rate may signal respiratory distress, metabolic imbalance, or infection, but it is not a specific indicator of nutritional status. It does not directly reflect whether the infant is receiving or retaining enough nutrition or fluids.

Correct Answer:

Express sorrow for the client's grief and offer to sit with her

Explanation:

Experiencing a spontaneous abortion is a deeply emotional and often traumatic event for clients, requiring compassionate and immediate emotional support. Expressing sorrow for the client’s grief acknowledges her loss and validates her feelings, which is an essential part of therapeutic communication. Offering to sit with her demonstrates empathy, presence, and a willingness to listen—key components of holistic, patient-centered care. This approach fosters trust, allows the client to express her emotions freely, and helps alleviate feelings of isolation or abandonment during a profoundly vulnerable time. Emotional support should take precedence over clinical tasks when a client is experiencing acute grief.

Why Other Options Are Wrong:

Offer to call the social worker to discuss the possibility of abortion

This is incorrect because the client has already experienced a miscarriage, not a planned abortion. Bringing up the topic of abortion is not only irrelevant but also potentially distressing. It shows a lack of sensitivity to the client’s current emotional state and could cause further confusion or pain. What the client needs now is comfort and understanding—not discussions about options that do not pertain to her current situation.

Reassure the client that the infertility specialist can help

This is incorrect because offering reassurance about future fertility shifts the focus away from the client's immediate emotional needs. While well-intentioned, it can minimize the grief she is experiencing right now. Statements like this may come across as dismissive or as an attempt to “fix” the situation rather than allowing space for mourning and healing.

Chart the vital signs and amount of vaginal bleeding

This is incorrect because, although physical assessments and documentation are essential nursing tasks, they are not the priority in this emotional context. The client is experiencing significant grief, and attending to her emotional well-being is more urgent at this moment. Addressing only the physical aspects of care would overlook the psychosocial dimension, which is central in situations involving loss.