HESI PN EXIT EXAM VERSION 3
After report, the LPN/LVN receives the laboratory values for 4 clients.
Which client requires the nurse’s immediate intervention? The client
who is…..
A. short of breath after a shower and has a hemoglobin of 8 grams
B. Bleeding from a finger stick and has a prothrombin time of 30
seconds
C. Febrile and has a WBC count of 14,000/mm3
D. Trembling and has a glucose level of 50 mg/dL – ANSWER- D.
Trembling and has a glucose level of 50 mg/dL
4 hours after administration of 20U of regular insulin, the client becomes
shaky and diaphoretic. What action should the nurse take?
A. Encourage the client to exercise
B. Administer a PRN dose of 10U of regular insulin
C. Give the client crackers and milk
D. Record the client’s reaction on the diabetic flow sheet – ANSWER- C.
Give the client crackers and milk
The LPN/LVN is changing the colostomy bag for a client who is
complaining of leakage of diarrheal stool under the disposable ostomy
bag. What action should the nurse implement to prevent leakage?
A. Place a 4X4 wick in the stoma opening
B. Apply a layer of zinc oxide ointment to the perimeter of the stoma
C. Cut the bag opening to the measurement of the stoma size
D. Administer a PRN antidiarrheal agent – ANSWER- C. Cut the bag
opening to the measurement of the stoma size
Prior to administering morphine sulfate (Morphine), the LPN/LVN takes
the client’s vital signs. Based on which finding should the nurse withhold
administration of the medication until the charge nurse is notified?
A. Temperature of 100.8F
B. A pulse rate of 150 beats per minute
C. A respiratory rate of 10 breaths per minute
D. A blood pressure of 180/110 – ANSWER- C. A respiratory rate of 10
breaths per minute
Following an open reduction of the tibian, the LPN/LVN notes fresh
bleeding on the client’s cast. Which intervention should the nurse
implement?
A. Assess the client’s hemoglobin to determine if the client is in shock
B. Call the surgeon and prepare to take the client back to the operating
room
C. Outline the area with ink and check it q15 minutes to see if the area
has increased
D. No action is required since postoperative bleeding can be expected –
ANSWER- C. Outline the area with ink and check it q15 minutes to see
if the area has increased
The is with a client when the healthcare provider explains that the
biopsy classifies the results as a T1N0M0 tumor. Later in the morning,
the client asks the nurse, “what do these letters T1N0M0, stand for?”
which response should the nurse provide first?
A. “The letters are used to predict the prognosis of the cancer or tumor.”
B. “The letters stand for tumor size, node involvement and metastasis.”
C. “Let me refer you to the charge nurse.”
D. “Are you confused? Would you like to talk?” – ANSWER- B. “The
letters stand for tumor size, node involvement and metastasis.”
The LPN/LVN plans to administer the rubella vaccine to a postpartum
client whose titer is < 1:8 and who is breastfeeding? what information
should the nurse provide this client?
A. The client should bottle feed and pump her breast for 3 days
following immunization
B. The vaccine is given to produce maternal antibodies before lactation
occurs
C. The infant will receive immunization through the mother’s breast
milk
D. The client should not get pregnant for 3 months after immunization –
ANSWER- B. The vaccine is given to produce maternal antibodies
before lactation occurs
In counting a client’s radial pulse, the LPN/LVN notes the pulse is weak
and irregular. To record the most accurate heart rate, what should the
nurse take? A. Recheck the radial pulse in thirty minutes
B. Palpate the radial pulse for thirty seconds and double the rate
C. Count the apical pulse rate for sixty seconds
D. Compare the radial pulse rate bilaterally and record the higher rate. –
ANSWER- C. Count the apical pulse rate for sixty seconds
Which structures are located in the subcutaneous layer of the skin?
A. Sebaceous and sweat glands
B. Melanin and Keratin
C. Sensory receptors and hair follicles
D. Adipose cells and blood vessels – ANSWER- D. Adipose cells and
blood vessels
The LPN/LVN in charge of a Nursing unit in a long term care facility.
Which task is best for the nurse to assign to an unlicensed assistive
personnel (UAP) who is helping with the care of several clients?
A. Measure the amount of a client’s residual urine after voiding
B. Cleanse the perineal area of a client with urinary incontinence
C. Insert a straight catheter to obtain a urine specimen for culture
D. Provide catheter care for a client with a suprapubic catheter –
ANSWER- B. Cleanse the perineal area of a client with urinary
incontinence
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