Question

The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?

Answer 1

Correct Answers:

Body weight.

Rationale :

🔶 Body weight is the most critical data point before transferring an unresponsive client, as it determines the number of staff needed and the type of equipment (e.g., mechanical lift) required to safely perform the transfer and prevent injury to both the client and the staff.

🔶 Unresponsive clients cannot assist in the movement, increasing the physical burden on caregivers. Knowing the client’s weight ensures proper planning for safe patient handling and mobility (SPHM).

🔶 Safe transfer protocols often rely on weight categories to guide lift type selection and number of personnel—e.g., over 200 lbs may require 3 staff and lift equipment.

🔶 Preventing musculoskeletal injuries in healthcare workers and avoiding skin shear or trauma in clients is a core safety goal during transfers.

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Answer 2

Correct Answers:

Explain that medication can only be provided to clients.

Rationale :

🟢 Medications in a hospital setting are legally and ethically restricted to prescribed clients only. The PN must not administer or provide medications to individuals who are not under medical care in the facility.

🟢 The spouse is not a patient and does not have a provider's order, a medical chart, or documented assessment, making it inappropriate and unsafe to provide any medication, even over-the-counter.

🟢 Providing medication to non-clients is considered unauthorized practice, may violate facility policies, and could lead to disciplinary or legal action against the nurse.

🟢 The PN should compassionately inform the spouse that medication cannot be given and may suggest that they obtain it from the hospital's public pharmacy or their personal supply if needed.

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Answer 3

Correct Answers:

Diphtheria.
Anthrax.
Tuberculosis.

Rationale :

🧬 B. Diphtheria

🧬 Diphtheria is a rare but highly contagious bacterial infection caused by Corynebacterium diphtheriae. It can lead to severe respiratory obstruction, myocarditis, and neurologic complications.

🧬 Due to its potential for outbreaks and the severity of illness, diphtheria is classified as a nationally notifiable disease by the CDC. Immediate reporting allows for rapid public health intervention, contact tracing, and prophylactic treatment of exposed individuals.

🧬 Reporting ensures coordinated responses, including quarantine measures, immunization status checks, and public awareness efforts to prevent further transmission.

🧪 D. Anthrax

🧪 Anthrax is a rare infectious disease caused by Bacillus anthracis, which can affect the skin, lungs, or gastrointestinal tract. It is a high-priority bioterrorism agent, especially in its inhalation form, which can be fatal without prompt treatment.

🧪 The CDC mandates immediate reporting of all suspected or confirmed anthrax cases to initiate a swift public health response and facilitate epidemiologic surveillance.

🧪 Early detection and public health notification are vital to limit the spread, begin prophylactic treatment for exposed populations, and identify potential sources of contamination.

🧤 E. Tuberculosis

🧤 Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains a major public health concern due to its airborne transmission and potential for drug resistance.

🧤 It is a reportable condition in all U.S. states because tracking active TB cases enables treatment monitoring, isolation protocols, and contact tracing to prevent widespread transmission.

🧤 Early reporting supports ongoing surveillance, facilitates the management of latent TB infections, and ensures adequate community health planning, especially in vulnerable populations.

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Answer 4

Correct Answers:

Acknowledge the client's anger and offer to listen.

Rationale :

🔶 Acknowledging the client’s emotional distress is a therapeutic communication technique that helps establish trust and validates their feelings. Paralysis can cause profound frustration, grief, and loss of control, leading to emotional outbursts.

🔶 By offering to listen, the PN shows empathy and respect, helping the client feel heard and supported, which can de-escalate aggression and reduce emotional tension.

🔶 This approach encourages the client to express underlying concerns rather than suppressing them, which is important for psychological healing and adaptation to new limitations.

🔶 Addressing the situation in the moment rather than avoiding it promotes emotional resolution and supports client-centered care.

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Answer 5

Correct Answers:

Instruct the UAP to protect the client's left side when transferring to a chair.

Rationale :

🟣 Neglect syndrome (also known as unilateral neglect) occurs most commonly after a right hemisphere stroke, causing the client to ignore the left side of the body and environment.

🟣 Clients may fail to recognize, move, or protect their affected side, which significantly increases the risk of injury during transfers or ambulation.

🟣 The PN should ensure safety by instructing the UAP to protect and support the client’s left side when moving or repositioning, helping prevent falls or trauma.

🟣 This intervention is both safety-focused and educational, reinforcing best practices for staff assisting clients with neurological deficits.

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Answer 6

Correct Answers:

Beneath the lower jaw.

Rationale :

🔵 The submandibular lymph nodes are located beneath the mandible (lower jaw), typically halfway between the angle and the tip of the jaw.

🔵 These nodes drain lymph from the mouth, lips, tongue, and submaxillary glands, making them important in assessing infections or malignancies in the oral and facial regions.

🔵 The PN palpates this area by gently rolling fingers under the jawline using circular motions to assess for enlargement, tenderness, or firmness, which may indicate an immune response or local pathology.

🔵 Proper anatomical knowledge helps ensure accurate lymph node assessment, supporting early detection of systemic or localized conditions.

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Answer 7

Correct Answers:

Replace the canister when full.

Rationale :

🟨 Replacing a suction canister that is full is a non-invasive, routine task that falls within the scope of practice for a UAP. It does not require clinical judgment or assessment and can be safely delegated.

🟨 The UAP can assist in maintaining cleanliness and functionality of the equipment by ensuring that waste is properly disposed of and the system remains operational.

🟨 Tasks involving tube placement checks, suction regulation, or securing medical devices require clinical decision-making and are reserved for licensed personnel, such as the PN or RN.

🟨 Proper delegation promotes efficiency while ensuring client safety and adherence to scope-of-practice regulations.

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Answer 8

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

🟦 Step 1 – Head Positioning: Tilting the head toward the affected side encourages optimal drainage of the irrigant and debris.

🟦 Step 2 – Basin Placement: Placing an emesis basin under the ear prevents mess and collects any expelled solution or cerumen.

🟦 Step 3 – Pinna Positioning: Pulling the ear up and back straightens the ear canal in adults, allowing safer and more effective access.

🟦 Step 4 – Irrigation: Irrigating gently with warm solution directed along the canal wall, not directly at the tympanic membrane, avoids trauma and facilitates removal of wax.

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Answer 9

Correct Answers:

Use a gloved finger to rub the suspension over the infected area.

Rationale :

🟩 Nystatin suspension treats oral candidiasis (thrush) by direct contact with the mucous membranes. Using a gloved finger allows the practical nurse to precisely apply the medication over the gums and other affected areas, ensuring optimal therapeutic coverage.

🟩 Infants cannot reliably swish and hold the suspension in their mouths, so manual application ensures the medication reaches the site of infection.

🟩 Applying it with a gloved finger also reduces the risk of aspiration and promotes better localized antifungal action.

🟩 This method is safe, effective, and developmentally appropriate for infants who cannot cooperate with traditional rinsing or sucking techniques.

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Answer 10

Correct Answers:

When death is imminent.

Rationale :

⚫ Cheyne-Stokes respirations are characterized by a cyclic pattern of deep, rapid breathing followed by gradual slowing and periods of apnea.

⚫ This respiratory pattern often indicates neurologic deterioration or a sign of approaching death, particularly in clients with end-stage illness, brain injury, or heart failure.

⚫ It reflects impaired respiratory centers in the brainstem and a loss of normal regulation of breathing.

⚫ Recognizing Cheyne-Stokes breathing helps the PN to provide comfort measures, family education, and anticipate end-of-life care needs.

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HESI LPN Exit~2024 Exam 1

No.

1 :
The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?

2 :
The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

3 :
According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.

4 :
A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

5 :
The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

6 :
Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

7 :
In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?

8 :
The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

9 :
In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?

10 :
In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?

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HESI LPN Exit~2024 Exam 1

No.

1 : The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?

2 : The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

3 : According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.

4 : A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

5 : The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

6 : Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

7 : In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?

8 : The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

9 : In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?

10 : In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?

1 :
The practical nurse (PN) is preparing to transfer an unresponsive client from the bed to a stretcher. Which client data is most important for the PN to obtain before beginning the transfer?

2 :
The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

3 :
According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.

4 :
A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

5 :
The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

6 :
Which location should the practical nurse (PN) palpate to determine if a client's submandibular lymph nodes are enlarged?

7 :
In providing care for a client with a nasogastric tube (NGT) connected to intermittent suction, which task can be assigned to the unlicensed assistive personnel (UAP)?

8 :
The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

9 :
In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?

10 :
In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?