HESI PN Exit Exam 2023

HESI PN Exit Exam 2023 Related

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A female Native American client who is receiving chemotherapy places a native artifact, an Indian medicine wheel, in her hospital room. The HCP removes the medicine wheel and tells the client, 'This type of thing does not belong in the hospital.' Which intervention should the PN implement?

  • A. Teach the client about the importance of adhering to the chemotherapy regimen
  • B. Act as the client's advocate when addressing the issue with the HCP
  • C. Consult with a Native American healer about the appropriate use of a medicine wheel
  • D. Inform the HCP about the client's feelings of culture shock
Correct Answer: B

Rationale: Acting as the client's advocate is the most appropriate intervention in this situation. Removing a culturally significant artifact without considering the client's beliefs and emotional needs can be distressing. By advocating for the client, the PN can ensure that the client's cultural practices are respected, which is crucial for her emotional and spiritual well-being during treatment. Choice A is incorrect because while chemotherapy adherence is important, it is not the most immediate concern in this scenario. The client's cultural needs and well-being take precedence. Choice C is incorrect because consulting with a Native American healer might not be necessary at this point and could delay addressing the immediate issue of advocating for the client's rights. Choice D is incorrect because simply reporting the client's feelings of culture shock to the HCP does not actively address the situation or advocate for the client's rights and cultural needs.

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While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?

  • A. Swab the oral cavity with a washcloth
  • B. Use oral swabs with normal saline
  • C. Provide a Yankauer tip for oral suction
  • D. Support the head with a small pillow
Correct Answer: B

Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.

Which of the following factors increases the risk of developing a pressure ulcer?

  • A. High-protein diet
  • B. Frequent repositioning
  • C. Immobility
  • D. Active range of motion exercises
Correct Answer: C

Rationale: Immobility is a significant risk factor for pressure ulcers because it leads to prolonged pressure on specific areas of the body, reducing blood flow and leading to tissue breakdown. Choices A, B, and D are incorrect. A high-protein diet can actually aid in wound healing and tissue repair. Frequent repositioning helps relieve pressure on bony prominences, reducing the risk of pressure ulcers. Active range of motion exercises can improve circulation and prevent muscle atrophy, thereby reducing the risk of pressure ulcers.

The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

  • A. Glucose should be taken if I have a fruity breath odor.
  • B. Glucose should be taken if I am urinating more than usual.
  • C. Glucose should be taken if I have blurred vision.
  • D. Glucose should be taken if I develop shakiness.
Correct Answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

Which task could the PN safely delegate to the UAP?

  • A. Oral feeding of a two-year-old child after application of a hip spica cast
  • B. Assessment of the placement and patency of a NG tube
  • C. Participation in staff rounds to record notes regarding client goals
  • D. Evaluation of a client's incisional pain following narcotic administration
Correct Answer: A

Rationale: The correct answer is A because oral feeding of a child is a task that can be safely delegated to an unlicensed assistive personnel (UAP). This task involves providing basic care and does not require specialized nursing skills. Choices B, C, and D involve assessments, recording client goals, and evaluating pain, respectively, which all require specialized nursing knowledge, judgment, and skills. These tasks are not within the scope of practice for a UAP.

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

  • A. I don't have any use for those who say the disease is going to win
  • B. I've found the support I need from my faith and family
  • C. I think I've had this disease for a long time, but the doctor did not find it
  • D. I understand that this is a disease that occurs mostly in older men
Correct Answer: B

Rationale: The correct answer is B because finding support in faith and family is a common way for individuals to cope with serious illnesses and come to terms with their prognosis. This statement indicates that the client has found a source of strength and comfort to deal with their situation. Choice A reflects defiance rather than acceptance. Choice C suggests denial or disbelief in the diagnosis. Choice D shows factual knowledge about the disease but does not necessarily indicate acceptance of the prognosis.

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