PN HESI Exit Exam

The correct answer is: Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations.

Explanation for the correct answer:

After a lobectomy, chest tubes are used to drain air, blood, and other fluids from the pleural space to allow the lung to re-expand and heal. A decrease in drainage, especially when the fluid becomes more serous and less bloody, typically indicates that the pleural space is clearing and the lung has re-expanded. If a chest x-ray confirms there is no pleural effusion (fluid) or air accumulation, it suggests that the chest tube may no longer be necessary for drainage. At this point, removal of the lower chest tube is appropriate, provided the x-ray findings support it.

Why the other options are incorrect:

Changing the Pleur-Evac system and re-assessing output in the empty chamber: This is unnecessary unless there is a malfunction or issue with the current drainage system. If the drainage output has diminished, but is still being properly drained, changing the system is not required. Re-assessing the output can be done without replacing the system.

Increasing the prescribed suction force to facilitate drainage of serosanguineous fluids: Increasing suction would not be appropriate because the reduced drainage indicates that the pleural space is healing. Additional suction could cause unnecessary trauma or negative pressure, potentially impeding the healing process or re-expansion of the lung.

Advancing the chest tube to ensure proper placement of the tip: Advancing the chest tube is unnecessary unless there is evidence that the tube has been dislodged or is not correctly positioned, which is not indicated in this case. If drainage is still occurring, and the x-ray shows no issues, advancing the tube could cause harm to the patient.

The correct answer is:

Outline the area with ink and check it q15 minutes to see if the area has increased.

Explanation for the Correct Answer:

In the immediate postoperative period, it is essential to monitor for complications such as bleeding. When fresh blood is noted on a cast, the most appropriate nursing action is to outline the area with ink and check it every 15 minutes. This practice allows for objective monitoring of the bleeding by visually tracking any increase in size. If the bleeding spreads beyond the marked boundary, this provides clear evidence that the hemorrhage is progressing and may require prompt medical intervention. This method aligns with the nursing process—assess before act—and supports early identification of a potentially life-threatening situation such as internal bleeding or compartment syndrome. Frequent reassessment ensures that changes are detected in a timely manner, allowing for faster and more appropriate clinical response.

Why the Other Options Are Wrong:

Assess the client's hemoglobin to determine if the client is in shock:

While hemoglobin levels can provide information about blood loss, they are not an immediate assessment tool for fresh external bleeding. Hemoglobin changes lag behind actual blood loss and would not reflect acute changes right away. Relying on lab values in this scenario delays appropriate nursing actions. Visual inspection and trending of bleeding progression take precedence and allow for real-time decision-making.

Call the surgeon and prepare to take the client back to the operating room:

This response is premature. Not all bleeding indicates the need for surgical intervention. Nurses are expected to collect objective data before escalating care. Without assessing the bleeding pattern or severity, contacting the surgeon and preparing for the OR may cause unnecessary alarm or actions. The nurse must first assess, document, and then notify the provider if bleeding increases.

No action is required since postoperative bleeding can be expected:

Assuming that all postoperative bleeding is benign is a dangerous misconception. While some oozing may be normal, fresh bleeding through a cast can signal a serious issue like hemorrhage or increased pressure beneath the cast. Failing to act could delay treatment and lead to complications, such as compartment syndrome. Nursing standards require vigilance, not complacency, especially in the immediate postoperative setting.

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 Answers: Supervise the UAP after reviewing the protocol.

Explanation:

When a nurse notices that a UAP has not followed a critical part of a protocol, the immediate step is to supervise the UAP and ensure they understand the correct protocol. By reviewing the protocol with the UAP, the nurse provides the necessary education to prevent future errors. This also reinforces the importance of each step in the protocol, helping the UAP understand its role in ensuring patient safety. Ongoing supervision ensures that the UAP can confidently follow the procedure, minimizing the risk of future mistakes.

Why the Other Choices Are Incorrect:

Report the UAP's omission to the charge nurse:

While reporting concerns is important, the immediate priority should be to correct the mistake through supervision and education. The nurse can report the issue to the charge nurse if the error becomes recurrent or leads to patient harm, but for now, the main focus should be on correcting the behavior and preventing further mistakes.

Complete an unusual occurrence report:

An unusual occurrence report is typically filed for incidents that result in harm or significantly deviate from standard care. Since this situation involved an omission that was corrected immediately, and there was no harm to the patient, an unusual occurrence report is not warranted unless the omission caused harm or a near-miss incident.

Assign the UAP to more stable clients the next day:

Simply assigning the UAP to more stable clients does not address the root cause of the issue. The priority should be educating and supervising the UAP to ensure the correct protocol is followed, regardless of the client’s condition. Changing assignments does not resolve the issue of protocol adherence.

Correct Answer:

Count the apical pulse rate for sixty seconds.

Explanation of the Correct Answer:

When a radial pulse is weak and irregular, the most accurate way to assess the heart rate is by counting the apical pulse for a full 60 seconds with a stethoscope. The apical pulse provides a more reliable measure of the heart rate, especially when irregularities are present. This method helps identify pulse deficits, which is the difference between the apical and radial pulses, and ensures a more accurate assessment of the client's heart activity.

Explanation of Incorrect Options:

Recheck the radial pulse in thirty minutes – Waiting for 30 minutes may delay necessary intervention if the irregular pulse is indicative of a serious issue, like arrhythmia. Immediate assessment via the apical pulse is the more appropriate response.

Palpate the radial pulse for thirty seconds and double the rate – A 30-second count may not accurately capture all the variations of an irregular pulse. A full 60-second count of the apical pulse is the most reliable and precise method for assessing the heart rate.

Compare the radial pulse rate bilaterally and record the higher rate – Comparing bilateral radial pulses identifies circulatory differences but does not provide an accurate heart rate measurement. For precision, the apical pulse is the best choice when irregularities are suspected.

The correct answer is:

Latex balloons

Explanation for the Correct Answer:

Latex balloons are the leading cause of non-food-related choking deaths in children. When a child inhales a deflated or broken piece of a balloon, the soft, flexible material can conform tightly to the trachea, making it extremely difficult to dislodge and causing a complete airway obstruction. Unlike rigid objects, latex cannot be easily grasped or removed with basic first aid maneuvers like the Heimlich. The risk of respiratory arrest is especially high due to the material’s ability to create an airtight seal. Pediatric safety experts and the American Academy of Pediatrics warn against giving latex balloons to young children due to their high risk of fatal aspiration.

Why the Other Options Are Wrong:

Broken rattles

While broken rattles can pose a choking hazard if small pieces detach, they are usually made of hard plastic or wood, which does not conform to the airway. These materials are more likely to cause a partial obstruction and may be easier to remove via back blows or abdominal thrusts. Additionally, modern rattles are subject to safety standards that minimize breakage and choking risks.

Buttons

Buttons are small and can be aspirated, but they are typically rigid and flat, which means they are less likely to create a complete seal in the airway. Though dangerous, they are generally more accessible during emergency interventions. Buttons represent a choking risk, but they do not have the same air-tight sealing capability as latex materials.

Pacifiers

Pacifiers are intentionally designed with wide guards or shields to prevent full insertion into a child’s mouth. This design greatly reduces the likelihood of aspiration. Even in the case of a broken pacifier, the risk of complete respiratory obstruction is lower than with latex balloons. While broken parts may pose a hazard, they are not among the most common causes of respiratory arrest in children.

Correct Answer:

Adipose cells and blood vessels

Explanation of the Correct Answer:

The subcutaneous layer, also known as the hypodermis, is the innermost layer of the skin. It is primarily made up of adipose tissue (fat cells) and blood vessels. This layer serves multiple functions, including insulation to regulate body temperature, energy storage, and cushioning for internal organs. The blood vessels in this layer are essential for thermoregulation, as they can adjust blood flow to help maintain body temperature.

Explanation of Incorrect Options:

Sebaceous and sweat glands – These glands are located in the dermis, not the subcutaneous layer. Sebaceous glands secrete oil (sebum) to lubricate the skin, and sweat glands help with thermoregulation by excreting sweat.

Melanin and Keratin – Melanin and keratin are found in the epidermis, which is the outermost layer of the skin. Melanin is responsible for skin pigmentation, while keratin provides strength and waterproofing.

Sensory receptors and hair follicles – These structures are located in the dermis layer. Sensory receptors detect stimuli like touch, pain, and temperature, while hair follicles are responsible for hair growth.

Correct Answer:

Paresthesia, paralysis, pedal pulses, pallor, and pain

Why this is Correct:

These five elements form the foundation of a neurovascular assessment and are critical after a total knee replacement. They help detect early signs of complications such as compartment syndrome, nerve compression, or impaired blood flow to the affected limb. Paresthesia (numbness or tingling) can indicate nerve involvement; paralysis may suggest severe nerve or spinal issues; pedal pulses confirm adequate circulation; pallor may reflect poor perfusion; and pain—especially if severe or unrelieved—can signal serious complications. Regular monitoring of these signs ensures prompt intervention and prevents long-term damage.

Why Others are Wrong:

Clear lung sounds, CPM on: While lung assessments and CPM use are important for respiratory status and joint mobility, they do not provide critical information about the limb’s vascular and neurological status immediately after surgery. These are secondary priorities compared to detecting neurovascular compromise.

Call bell, side rails, bed in low position, and ambulation aids: These are standard safety precautions, essential for fall prevention, but they do not assess for limb viability or detect complications like blood clots or nerve damage. They support safety, not clinical deterioration detection.

Blood pressure 138/88, pain scale 7, and respirations 22: These are routine vital signs and offer a general view of the client's systemic condition. However, they don’t specifically evaluate the operated leg. Pain is relevant, but without assessing for circulation and nerve function, important details could be missed.