HESI PN EXIT 2025
QUESTIONS AND ANSWERS
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? - ANSWER-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? - ANSWER-Outline the area with
ink and check it q15 minutes to see if the area has increased
The LPN 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? - ANSWER-"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? -
ANSWER-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? - ANSWER-Count the apical
pulse rate for sixty seconds
Which structures are located in the subcutaneous layer of the skin? - ANSWER-
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? - ANSWER-Cleanse the perineal area of a client with
urinary incontinence
A client requires application of an eye shield to the right eye. What should the
nurse do in
order to apply tape in which direction to anchor the shield most effectively? -
ANSWER-Longitudinally from the right forehead to the right cheek
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? -
ANSWER-Palpate the bladder for distention
A client presents in the clinic because of generalized swelling after a bee sting.
What
,intervention should the nurse implement first? - ANSWER-Determine respiratory
status and apply a pulse oximeter
The LPN/LVN is administering multiple medications to a 78-year-old client
because of
problems related to polypharmacy. At this client's age, which assessment is most
important for the nurse to make? - ANSWER-Cumulative serum drug levels and
toxicity
In obtaining an orthostatic vital sign measurement, what action should the nurse
take
first? - ANSWER-Instruct the client to lie supine
A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What
interventions should the nurse expect to implement to establish hydration in the
immediate postoperative period? - ANSWER-Nipple feedings with glucose water
Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the
nurse.
After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw
the
catheter while the client is in a Semi-Fowler's position. However, the nurse meets
resistance and the clients' voices discomfort. What action should the nurse take
next? - ANSWER-Assist the client in taking a series of deep breaths
, During morning report the PN learns that an assigned client has phlebitis from a
intravenous access device. What will the PN observe in this client? - ANSWER-
Redness, warmth, and edema of the site
The PN is caring for a client with atrial fibrillation. What would be an expected
finding
when assessing this client? - ANSWER-Heart rate 88 and irregular
A client's blood pressure is unusually elevated. Which factors would contribute to
this
client's blood pressure elevation? - ANSWER-stress
To obtain an estimate of a client's systolic blood pressure, what action should the
PN take
first? - ANSWER-Palpate the client's brachial pulse
A client reports feeling numbness and tingling in extremities. What action should
the PN
implement? - ANSWER-Review the client's serum electrolyte levels
Immediately after birth, which nursing intervention has the highest priority for the
newborn infant? - ANSWER-Preventing heat loss and neonatal cold stress
QUESTIONS AND ANSWERS
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? - ANSWER-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? - ANSWER-Outline the area with
ink and check it q15 minutes to see if the area has increased
The LPN 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? - ANSWER-"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? -
ANSWER-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? - ANSWER-Count the apical
pulse rate for sixty seconds
Which structures are located in the subcutaneous layer of the skin? - ANSWER-
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? - ANSWER-Cleanse the perineal area of a client with
urinary incontinence
A client requires application of an eye shield to the right eye. What should the
nurse do in
order to apply tape in which direction to anchor the shield most effectively? -
ANSWER-Longitudinally from the right forehead to the right cheek
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? -
ANSWER-Palpate the bladder for distention
A client presents in the clinic because of generalized swelling after a bee sting.
What
,intervention should the nurse implement first? - ANSWER-Determine respiratory
status and apply a pulse oximeter
The LPN/LVN is administering multiple medications to a 78-year-old client
because of
problems related to polypharmacy. At this client's age, which assessment is most
important for the nurse to make? - ANSWER-Cumulative serum drug levels and
toxicity
In obtaining an orthostatic vital sign measurement, what action should the nurse
take
first? - ANSWER-Instruct the client to lie supine
A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What
interventions should the nurse expect to implement to establish hydration in the
immediate postoperative period? - ANSWER-Nipple feedings with glucose water
Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the
nurse.
After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw
the
catheter while the client is in a Semi-Fowler's position. However, the nurse meets
resistance and the clients' voices discomfort. What action should the nurse take
next? - ANSWER-Assist the client in taking a series of deep breaths
, During morning report the PN learns that an assigned client has phlebitis from a
intravenous access device. What will the PN observe in this client? - ANSWER-
Redness, warmth, and edema of the site
The PN is caring for a client with atrial fibrillation. What would be an expected
finding
when assessing this client? - ANSWER-Heart rate 88 and irregular
A client's blood pressure is unusually elevated. Which factors would contribute to
this
client's blood pressure elevation? - ANSWER-stress
To obtain an estimate of a client's systolic blood pressure, what action should the
PN take
first? - ANSWER-Palpate the client's brachial pulse
A client reports feeling numbness and tingling in extremities. What action should
the PN
implement? - ANSWER-Review the client's serum electrolyte levels
Immediately after birth, which nursing intervention has the highest priority for the
newborn infant? - ANSWER-Preventing heat loss and neonatal cold stress
