PN HESI Exit Exam

PN HESI Exit Exam

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Free PN HESI Exit Exam Questions

1.

36 hours after delivery, the nurse determines a client's 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

  • Ask the client when her last bowel movement occurred

  • Catheterize the client and record the amount

  • Assess the amount of lochia

Explanation

Correct Answer:

Palpate the bladder for distention

Explanation of the Correct Answer:


At 36 hours postpartum, the uterus should be at or slightly below the umbilicus and midline. If the uterus is displaced to the right, it is often due to a full bladder pressing against the uterus, causing it to shift out of position. The first action is to palpate the bladder to assess for distention. A distended bladder can prevent proper uterine contraction, increasing the risk of postpartum hemorrhage. By confirming whether the bladder is full, the nurse can decide if the client needs to urinate or if catheterization is necessary. Ensuring the bladder is empty helps the uterus contract more effectively and reduces the risk of complications.

Explanation of Incorrect Options:

Ask the client when her last bowel movement occurred – While constipation is common postpartum, it typically does not cause uterine displacement. The priority is addressing bladder distention, which directly affects the uterus and can lead to complications like uterine atony.

Catheterize the client and record the amount – Catheterization might be necessary if the client cannot void, but the first step is to assess for bladder distention. This helps determine whether the bladder is indeed full and whether catheterization is required.

Assess the amount of lochia – While monitoring lochia is important, it does not address the immediate cause of uterine displacement. A displaced uterus due to a full bladder is a more immediate concern that could contribute to increased bleeding, making bladder assessment the priority


2.

The LPN/LVN is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area

  • Duodenum

  • Gastric Pylorus

  • Liver

  • Spleen

Explanation

Correct Answer:

Liver

Explanation:

The right upper hypochondriac region of the abdomen primarily contains the liver, specifically the right lobe of the liver. The liver is the largest solid organ in the body and plays critical roles in metabolism, detoxification, and bile production. The gallbladder is also located beneath the liver in this region. When a nurse palpates this area, they may assess for signs of liver enlargement (hepatomegaly), tenderness, or other abnormalities, which could be indicative of liver disease, gallbladder dysfunction, or hepatic congestion. This region is crucial for evaluating conditions related to the liver and bile ducts.

Why Other Options Are Wrong:

Duodenum


This is incorrect because the duodenum, which is the first portion of the small intestine, is located in the epigastric and right lumbar regions, not the right upper hypochondriac region. The duodenum plays a critical role in digestion and absorption but does not lie directly under the area being palpated in the right upper hypochondriac region.

Gastric Pylorus

This is incorrect because the pylorus is part of the lower portion of the stomach that connects to the duodenum. It is primarily located in the epigastric region, which is above the right upper hypochondriac region. The pylorus helps regulate the passage of partially digested food from the stomach into the small intestine but does not lie under the right upper hypochondriac region.

Spleen

This is incorrect because the spleen is located in the left upper hypochondriac region, not the right. The spleen is involved in immune function and blood filtration, but it does not lie beneath the right upper hypochondriac region, which is where the liver is located.


3.

The LPN/LVN receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site

  • Umbilical area of the abdomen

  • Antecubital fossae of the arm

  • Chest wall below the clavicle

  • Dorsal surface of the hand

Explanation

Correct Answer: Chest wall below the clavicle

For a central intravenous (IV) infusion, the catheter is typically inserted into a large central vein such as the subclavian vein, which is located below the clavicle. This area is a common site for central line insertion, and assessing this site for the integrity of the central IV access is essential. The nurse should focus on the chest wall below the clavicle to check for any complications such as infection, bleeding, or dislodgement of the catheter.

Why the other options are incorrect:

Umbilical area of the abdomen


This is not a site for central IV access in adults. The umbilical area is used for umbilical lines in newborns but is not appropriate for adults.

Antecubital fossae of the arm

While this is a common site for peripheral IV placement, it is not used for central lines. Central lines are typically placed in the subclavian, jugular, or femoral veins, not in the arm's antecubital fossa.

Dorsal surface of the hand

This area is also used for peripheral IV access, but central lines are placed in larger veins, such as those in the chest, neck, or groin. Thus, the dorsal surface of the hand is not the appropriate site for assessing central IV infusion.


4.

The nurse is caring for a school age child with sickle cell anemia presenting with an upper respiratory infection and fever. Which action should the nurse take first to minimize vaso occlusive crisis?

  • Initiate prescribed intravenous fluids.

  • Apply oxygen via nasal cannula.

  • Administer pain medication.

  • Determine tolerance of activity.

Explanation

Explanation
Correct Answer: A) Initiate prescribed intravenous fluids.
In sickle cell anemia, dehydration is the primary trigger for vaso-occlusive crisis (VOC). When the body becomes dehydrated, the blood becomes more viscous and concentrated, causing sickle-shaped red blood cells to clump together and obstruct small blood vessels, leading to severe pain and tissue ischemia. Initiating IV fluids is the priority first action because it directly addresses and prevents the primary precipitating factor — dehydration — by restoring circulating volume, diluting the blood, and improving blood flow through the microvasculature.
5.

A client arrives to the emergent care clinic describing pain, tenderness, and swelling of the right knee and an inability to bear weight on the leg. The nurse obtains a history from the client that a popping sound was suddenly heard in the right knee while playing tennis. Based on the history and assessment, which injury should the nurse expect has occurred?

  • Tendonitis.

  • Fracture of the patella.

  • Rotator cuff tear.

  • Ligament sprain.

Explanation

Explanation

Correct Answer: D) Ligament sprain.

The combination of a sudden audible popping sound at the time of injury, immediate pain, swelling, tenderness, and inability to bear weight on the knee following a sports activity is the classic presentation of a ligament sprain — most commonly an anterior cruciate ligament (ACL) tear. The "pop" heard at the moment of injury is characteristic of ligamentous rupture as the fibers tear under sudden stress. Tendonitis develops gradually from repetitive overuse and does not present with a sudden popping sound. A patellar fracture would result from direct trauma or a fall, not a twisting sports injury. A rotator cuff tear involves the shoulder, not the knee.
6.

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

  • "This is the emergency door. Are you looking for the bathroom?"

  • "You look confused. Would you like to talk about your feelings?"

  • "Let's go back to your room. Your doctor does not want you to be walking alone."

  • "You want to go outside at this time of night? It's dangerous out there."

Explanation

Correct Answer:


"This is the emergency door. Are you looking for the bathroom?"


Explanation of the Correct Answer:


For patients with Alzheimer's disease, confusion and disorientation are common symptoms. In such cases, the nurse should provide clear, simple, and gentle communication. The response in the correct option acknowledges the patient's confusion and redirects them in a calm and reassuring way. By offering a potential alternative ("Are you looking for the bathroom?"), the nurse helps the patient feel understood and reduces anxiety. Redirecting the patient to a safer activity (e.g., using the bathroom instead of opening an emergency door) is an effective approach, as it minimizes potential risks and helps maintain a sense of security without escalating confusion or distress.


Explanation of Incorrect Choices:


"You look confused. Would you like to talk about your feelings?"

While acknowledging confusion is important, asking a patient with Alzheimer's disease to talk about their feelings may not be productive. Cognitive impairments in Alzheimer's can make it difficult for the patient to understand complex questions or communicate their emotions effectively. The goal should be clear, direct action rather than asking open-ended questions that may lead to more confusion.


"Let's go back to your room. Your doctor does not want you to be walking alone."

This response might create more confusion for the patient. The mention of the doctor’s instructions could be difficult for the patient to comprehend or retain, which may increase anxiety or resistance. A simpler, more direct approach, such as offering assistance or guiding the patient back to their room without referencing the doctor's orders, would be more effective.


"You want to go outside at this time of night? It's dangerous out there."

This response could increase the patient's anxiety or resistance. Telling the patient that it is dangerous outside may heighten their confusion and make them feel defensive or upset. The confrontational tone ("It's dangerous out there") can add to the disorientation. A calmer, more supportive approach that redirects the patient to a safer activity is preferable.

7.

The LPN/LVN 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

  • Inform the UAP that the suction is available at the bedside

  • Instruct the UAP to notify the PN if the client begins to choke

  • Observe the UAP's ability to implement precautions during feed

  • Ask the UAP about previous experience performing this skill

Explanation

The correct answer is: Observe the UAP's ability to implement precautions during feeding.

Explanation for the correct answer:

When delegating tasks to unlicensed assistive personnel (UAP), the nurse must ensure that the UAP understands how to perform the task safely and effectively, especially when it involves a client who is at risk for aspiration. By directly observing the UAP during the feeding process, the nurse can ensure that the UAP is following the necessary precautions (such as positioning the client correctly, offering small bites, and monitoring the swallowing process). This observation allows the nurse to assess whether the UAP is applying the correct precautions and if further education or guidance is necessary to ensure the client's safety.

Why the other options are wrong:

Inform the UAP that the suction is available at the bedside: While it is important to have suction available in case of an emergency, merely informing the UAP about its availability does not ensure that the UAP knows how to prevent aspiration. Prevention, rather than just reaction, is key. The nurse should focus on making sure the UAP knows how to perform the task correctly to reduce the risk of aspiration in the first place.

Instruct the UAP to notify the PN if the client begins to choke: Although it is important for the UAP to notify the nurse if the client begins to choke, this step alone is insufficient. The nurse needs to confirm that the UAP is competent in recognizing the signs of aspiration and knows how to prevent it. Prevention includes positioning the client properly, controlling the pace of feeding, and monitoring the client's swallowing, not just responding to an emergency.

Ask the UAP about previous experience performing this skill: While understanding the UAP's previous experience can be helpful, it is more critical to observe their ability to perform the task in the present moment. Even if the UAP has performed similar tasks before, it is essential to ensure that they are following the correct precautions during this specific feeding session.


8.

The parents of a 4-week-old male infant report that he eats well but vomits after each feeding. Which finding should the practical nurse (PN) identify if the baby is receiving inadequate nutrition

  • Absent Moro reflex

  • Hypoactive bowel sounds

  • Tachypnea

  • Sunken fontanels

Explanation

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.


9.

The nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

  • Increase daily intake of sodium in diet.

  • Avoid extreme environmental temperatures.

  • Use a walker when weakness occurs.

  • Take prescribed cortisone accurately.

Explanation

Explanation
Correct Answer: D) Take prescribed cortisone accurately.
In Addison's disease, the adrenal glands fail to produce adequate cortisol and aldosterone. Cortisone replacement therapy is lifesaving and must be taken consistently and accurately as prescribed. Missing doses or abrupt discontinuation can precipitate an Addisonian crisis, a life-threatening emergency characterized by severe hypotension, shock, and electrolyte imbalances.

Increasing sodium intake is beneficial but is secondary to medication adherence. Avoiding extreme temperatures is helpful as temperature regulation is impaired, but it is not the most critical instruction. Using a walker addresses safety for weakness but does not address the underlying hormonal deficiency that is the core management priority.
10.

The nurse is conducting an admission assessment of an 11-month old infant with heart failure who is scheduled for repair of restenosis of coarctation of the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. Which pathophysiologic mechanism supports these findings?

  • The aortic semilunar valve obstructs blood flow into the systemic circulation.

  • The pulmonic valve prevents adequate blood volume into the pulmonary circulation.

  • An opening in the atrial septum causes a murmur due to a turbulent left to right shunt.

  • The lumen of the aorta reduces the volume of blood flow to the lower extremities.

Explanation

Explanation
Correct Answer: D) The lumen of the aorta reduces the volume of blood flow to the lower extremities.
Coarctation of the aorta is a narrowing of the aortic lumen that obstructs blood flow to the lower body. This narrowing causes higher blood pressure and stronger pulses in the upper extremities (arms) proximal to the obstruction, while producing lower blood pressure and weak or absent femoral pulses in the lower extremities distal to the obstruction. This classic upper-to-lower extremity blood pressure differential is the hallmark finding of aortic coarctation. The aortic semilunar valve, pulmonic valve, and atrial septal defects are separate structural abnormalities that do not produce this specific pattern of findings.

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