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HESI Exit LPN Exam 1
Question 1:
The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid
medication via a client's feeding tube system as seen in the picture. What action should the PN
take?
A. Demonstrate how to administer medication via a feeding tube.
B. Confirm that the medication is only administered once daily
C. Determine if the medication is compatible with the solution.
D. Offer to assist in calculating the rate of flow for the mixture.
Answer and Explanation
Choice A:
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The picture shows that the newly hired PN is about to make a serious error by adding the medication
directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the
medication. The PN should demonstrate how to administer medication via a feeding tube correctly,
which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing
again, and resuming the feeding.
Choice B:
Confirming that the medication is only administered once daily is not relevant or helpful, as it does
not address the error or teach the correct technique of administering medication via a feeding tube.
Choice C:
Determining if the medication is compatible with the solution is not necessary or appropriate, as the
medication should not be mixed with the solution in the first place, but given separately through the
feeding tube.
Choice D:
Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there
should be no mixture of medication and solution in the feeding bag, but separate administration of
each through the feeding tube.
Question 2:
A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and
the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not
understand how awful it is. I am a burden to my family because I cannot hold a job. I do not
know how much longer I can live this way." Which information is most important for the
practical nurse (PN) to ask in response to the client's statements?
A. Question about which rituals are most often used to reduce anxiety.
B. Ask if the obsessions and compulsions interfere with sleep.
C. Inquire if the distress could lead to considering suicide as an option.
D. Determine what makes the client think people are laughing.
Answer and Explanation
Choice A:
Questioning about which rituals are most often used to reduce anxiety is not a priority and may
reinforce the client's compulsive behavior.
Choice B:
Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address
the client's emotional distress.
Choice C:
This is the most important information for the PN to ask because it assesses the client's risk for self-
harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and
impaired functioning, which are potential warning signs of suicide. The PN should ask the client
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directly about any thoughts or plans of harming themselves and provide support and safety measures
as needed.
Choice D:
Determining what makes the client think people are laughing is not a priority and may not be helpful
for the client's perception of reality.
Question 3:
An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated,
staggers out into the corridor, and demands to be set free.
After assisting the client back to bed and administering pain medication, which intervention is
best for the practical nurse (PN) to implement?
A. Administer a prescribed narcotic antagonist to reverse the effects of any analgesic accumulation
B. Notify the healthcare provider and request a prescription for restraints to minimize the client's
danger to self.
C. Raise the side rails and notify the family to come and stay until the client is reoriented and
cooperative
D. Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the
client is resting.
Answer and Explanation
Choice A:
Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's
agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia,
infection, electrolyte imbalance, or sensory deprivation.
Choice B:
Notifying the healthcare provider and requesting a prescription for restraints may not be the best
intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be
used only as a last resort when other measures have failed or when there is an imminent risk of harm.
Choice C:
The client may be experiencing postoperative delirium, which is a transient state of confusion,
disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients.
The PN should raise the side rails and notify the family to come and stay with the client, as this can
provide safety, comfort, and reassurance for the client
Choice D:
Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not
be sufficient or effective, as the client may still try to get out of bed or become more agitated by
being left alone. The PN should involve the family or stay with the client until he or she is calm and
oriented.
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Question 4:
Which actions should the practical nurse (PN) include when assessing a client for signs and
symptoms of fluid volume excess? (Select all that apply.)
A. Palpate the rate and volume of the pulse.
B. Check fingernails for the presence of clubbing.
C. Measure body weight at the same time daily
D. Observe the color and amount of urineE. Compare muscle strength of both arms.
Answer and ExplanationChoice A:
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily,
and observe the color and amount of urine when assessing a client for signs and symptoms of fluid
volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance
systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema,
oliguria, or dark urine.
Choice B:
Checking fingernails for the presence of clubbing is not relevant for assessing fluid volume excess, as
clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and
nails.
Choice C:
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily,
and observe the color and amount of urine when assessing a client for signs and symptoms of fluid
volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance
systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema,
oliguria, or dark urine.
Choice D:
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily,
and observe the color and amount of urine when assessing a client for signs and symptoms of fluid
volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance
systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema,
oliguria, or dark urine.
Choice E:
Comparing muscle strength of both arms is not relevant for assessing fluid volume excess, as muscle
weakness is not a specific sign of fluid overload, but may be caused by various factors such as
electrolyte imbalance, nerve damage, or fatigue.
Question 5:
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse
(PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action
should the PN take first?
A. Obtain a 30 mL syringe and a vial of sterile water.
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HESI Exit LPN Exam 1
Question 1:
The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid
medication via a client's feeding tube system as seen in the picture. What action should the PN
take?
A. Demonstrate how to administer medication via a feeding tube.
B. Confirm that the medication is only administered once daily
C. Determine if the medication is compatible with the solution.
D. Offer to assist in calculating the rate of flow for the mixture.
Answer and Explanation
Choice A:
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The picture shows that the newly hired PN is about to make a serious error by adding the medication
directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the
medication. The PN should demonstrate how to administer medication via a feeding tube correctly,
which involves stopping the feeding, flushing the tube with water, instilling the medication, flushing
again, and resuming the feeding.
Choice B:
Confirming that the medication is only administered once daily is not relevant or helpful, as it does
not address the error or teach the correct technique of administering medication via a feeding tube.
Choice C:
Determining if the medication is compatible with the solution is not necessary or appropriate, as the
medication should not be mixed with the solution in the first place, but given separately through the
feeding tube.
Choice D:
Offering to assist in calculating the rate of flow for the mixture is not relevant or helpful, as there
should be no mixture of medication and solution in the feeding bag, but separate administration of
each through the feeding tube.
Question 2:
A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and
the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not
understand how awful it is. I am a burden to my family because I cannot hold a job. I do not
know how much longer I can live this way." Which information is most important for the
practical nurse (PN) to ask in response to the client's statements?
A. Question about which rituals are most often used to reduce anxiety.
B. Ask if the obsessions and compulsions interfere with sleep.
C. Inquire if the distress could lead to considering suicide as an option.
D. Determine what makes the client think people are laughing.
Answer and Explanation
Choice A:
Questioning about which rituals are most often used to reduce anxiety is not a priority and may
reinforce the client's compulsive behavior.
Choice B:
Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address
the client's emotional distress.
Choice C:
This is the most important information for the PN to ask because it assesses the client's risk for self-
harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and
impaired functioning, which are potential warning signs of suicide. The PN should ask the client
Downloaded by James Banks ()
, lOMoARcPSD|61299927
directly about any thoughts or plans of harming themselves and provide support and safety measures
as needed.
Choice D:
Determining what makes the client think people are laughing is not a priority and may not be helpful
for the client's perception of reality.
Question 3:
An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated,
staggers out into the corridor, and demands to be set free.
After assisting the client back to bed and administering pain medication, which intervention is
best for the practical nurse (PN) to implement?
A. Administer a prescribed narcotic antagonist to reverse the effects of any analgesic accumulation
B. Notify the healthcare provider and request a prescription for restraints to minimize the client's
danger to self.
C. Raise the side rails and notify the family to come and stay until the client is reoriented and
cooperative
D. Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the
client is resting.
Answer and Explanation
Choice A:
Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's
agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia,
infection, electrolyte imbalance, or sensory deprivation.
Choice B:
Notifying the healthcare provider and requesting a prescription for restraints may not be the best
intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be
used only as a last resort when other measures have failed or when there is an imminent risk of harm.
Choice C:
The client may be experiencing postoperative delirium, which is a transient state of confusion,
disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients.
The PN should raise the side rails and notify the family to come and stay with the client, as this can
provide safety, comfort, and reassurance for the client
Choice D:
Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not
be sufficient or effective, as the client may still try to get out of bed or become more agitated by
being left alone. The PN should involve the family or stay with the client until he or she is calm and
oriented.
Downloaded by James Banks ()
, lOMoARcPSD|61299927
Question 4:
Which actions should the practical nurse (PN) include when assessing a client for signs and
symptoms of fluid volume excess? (Select all that apply.)
A. Palpate the rate and volume of the pulse.
B. Check fingernails for the presence of clubbing.
C. Measure body weight at the same time daily
D. Observe the color and amount of urineE. Compare muscle strength of both arms.
Answer and ExplanationChoice A:
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily,
and observe the color and amount of urine when assessing a client for signs and symptoms of fluid
volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance
systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema,
oliguria, or dark urine.
Choice B:
Checking fingernails for the presence of clubbing is not relevant for assessing fluid volume excess, as
clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and
nails.
Choice C:
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily,
and observe the color and amount of urine when assessing a client for signs and symptoms of fluid
volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance
systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema,
oliguria, or dark urine.
Choice D:
The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily,
and observe the color and amount of urine when assessing a client for signs and symptoms of fluid
volume excess. These actions can help detect changes in the cardiovascular, renal, and fluid balance
systems that may indicate fluid overload, such as tachycardia, bounding pulse, weight gain, edema,
oliguria, or dark urine.
Choice E:
Comparing muscle strength of both arms is not relevant for assessing fluid volume excess, as muscle
weakness is not a specific sign of fluid overload, but may be caused by various factors such as
electrolyte imbalance, nerve damage, or fatigue.
Question 5:
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse
(PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action
should the PN take first?
A. Obtain a 30 mL syringe and a vial of sterile water.
Downloaded by James Banks ()
