Question

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?

Answer 1

Correct Answers:

Determine if the medication is compatible with the solution.

Rationale :

🔷 Medication compatibility with enteral nutrition is crucial to avoid interactions that could clog the tube or reduce medication effectiveness.

🔷 Many liquid medications can precipitate or become ineffective when mixed with tube feeding solutions.

🔷 Confirming compatibility helps prevent tube obstruction, altered drug absorption, or adverse effects.

🔷 The PN has a responsibility to ensure safety before administration, especially when observing a newly hired PN.

🔷 Professional nursing standards include verifying medication and solution interactions as part of safe practice.

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Answer 2

Correct Answers:

Inquire if the distress could lead to considering suicide as an option.

Rationale :

🔶 The client verbalized hopelessness and being a burden, which are warning signs of suicidal ideation.

🔶 Suicide risk assessment is a priority intervention in psychiatric care, especially when patients express despair.

🔶 Asking directly about suicidal thoughts is a professional and appropriate nursing action; it does not increase risk.

🔶 Early identification allows for prompt referral and safety measures to prevent self-harm.

🔶 This response is guided by the mental health priority of protecting life and ensuring safety.

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Answer 3

Correct Answers:

Instruct a UAP to keep the upper side rails up and check on the client every 15 minutes until the client is resting.

Rationale :

💠 Frequent monitoring helps prevent falls and injury while avoiding unnecessary restraint.

💠 Postoperative clients may become delirious due to pain, medication, or unfamiliar environments.

💠 Keeping the side rails up is a non-restrictive safety intervention that protects the client.

💠 Delegating checks every 15 minutes ensures early detection of agitation recurrence.

💠 This action supports client-centered care while allowing time for the pain medication to take effect.

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Answer 4

Correct Answers:

Palpate the rate and volume of the pulse.
Measure body weight at the same time daily.
Observe the color and amount of urine.

Rationale :

Palpate the rate and volume of the pulse

Bounding pulses are a classic sign of fluid volume overload due to increased intravascular volume.
Assessment of pulse strength and rhythm helps detect early signs of cardiac stress.
Tachycardia and increased pulse pressure often accompany hypervolemia.
It’s a quick and effective bedside circulatory assessment.

Measure body weight at the same time daily

Daily weights are the most sensitive indicator of fluid retention or loss.
Monitoring weight consistently at the same time helps eliminate inaccuracies due to food or fluid intake.
A gain of 2.2 pounds (1 kg) equals 1 liter of fluid retention.
This is a key practice in clients with heart failure, kidney disease, or fluid imbalances.

Observe the color and amount of urine

Decreased urine output and dark, concentrated urine may indicate impaired renal perfusion or fluid retention.
In contrast, clear, dilute urine in large amounts could reflect overhydration.
Urine assessment provides critical insight into renal function and fluid balance.
It also supports early identification of complications in fluid status.

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Answer 5

Correct Answers:

Consult with the charge nurse about the catheter.

Rationale :

🟣 #18 French catheters with 30 mL balloons are considered too large for most adult female clients, especially those with low body weight like 50 kg.

🟣 The recommended catheter size for adult females is 12 to 14 French, with a 5 to 10 mL balloon, to minimize trauma and discomfort.

🟣 Inserting an oversized catheter may cause urethral trauma, bladder irritation, or urinary tract infections.

🟣 The PN has a responsibility to question inappropriate or unsafe orders or supplies and advocate for safe client care.

🟣 Consulting with the charge nurse before proceeding ensures confirmation of correct equipment and adherence to best practices.

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Answer 6

Correct Answers:

Begin frequent feedings of breast milk or formula.

Rationale :

🟡 A blood glucose level of 40 mg/dL, while technically within the low-normal neonatal range, becomes clinically concerning when the infant is symptomatic, such as being jittery.

🟡 The infant is large for gestational age (LGA) due to maternal gestational diabetes, increasing the risk for neonatal hypoglycemia from hyperinsulinemia.

🟡 Frequent early feedings with breast milk or formula help stabilize glucose levels by providing a consistent source of carbohydrates, reducing the risk of complications like seizures or brain injury.

🟡 Breast milk is preferred and effective; if the infant can suckle, oral feeding is the first intervention before using IV or glucose solutions.

🟡 Timely feeding reduces the risk of further glucose decline and supports normal metabolic transition post-birth.

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Answer 7

Correct Answers:

Weigh every morning.

Rationale :

⚪ Daily weight monitoring is essential for clients with chronic kidney disease (CKD) to assess fluid balance and detect early signs of fluid retention.

⚪ Sudden weight gain is often the first indicator of fluid overload, which can exacerbate hypertension and contribute to neurological symptoms like confusion.

⚪ CKD impairs the kidneys’ ability to regulate fluid and electrolytes, making fluid management a critical component of care.

⚪ Morning weight (before food, after voiding) offers a consistent baseline and helps the healthcare team adjust dialysis, fluid restriction, or diuretics appropriately.

⚪ This practice directly supports early intervention, reducing the risk of complications such as pulmonary edema or hypertensive crisis.

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Answer 8

Correct Answers:

Small gauze pad.
Paper tape.
Exam gloves.

Rationale :

Small gauze pad

Essential for applying direct pressure after removing the saline lock to stop any bleeding.
Helps prevent contamination and supports site healing.

Paper tape

Used to secure the gauze dressing over the IV site once pressure is applied and bleeding has stopped.
Hypoallergenic and gentle for securing skin-level dressings.

Exam gloves

Standard precaution for any procedure involving blood or open skin.
Protects both the nurse and client from cross-contamination.

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Answer 9

Correct Answers:

Remind the client what day of the week it is.

Rationale :

🔵 The client is exhibiting acute confusion likely due to the change in environment, a common and temporary occurrence in newly admitted older adults.

🔵 Simple reorientation strategies, such as reminding the client of the date or time, are effective and non-invasive interventions.

🔵 These actions support cognitive function, reduce anxiety, and promote a sense of security and familiarity.

🔵 There’s no evidence of chronic confusion or dementia; thus, active engagement and redirection are more appropriate than documentation or escalation.

🔵 Reassuring and reorienting the client also supports emotional well-being and helps with adjusting to the facility.

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Answer 10

Correct Answers:

Monitor the child's oxygen saturation level via pulse oximetry.

Rationale :

🟠 The child’s symptoms — irritability, tachypnea, and stridor at rest — indicate increasing respiratory distress, which can quickly become a medical emergency in pediatric clients.

🟠 Pulse oximetry is the most effective, non-invasive method to monitor for hypoxia, ensuring timely recognition of oxygen desaturation.

🟠 Monitoring oxygen saturation allows for prompt escalation of care, including possible oxygen therapy or respiratory support.

🟠 Children with croup are at risk for upper airway obstruction, and early detection of decreased oxygen levels helps prevent respiratory failure.

🟠 This intervention reflects the priority action: assess before you intervene, especially when respiratory compromise is suspected.

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LPN HESI Exit-2023 Exam 2

No.

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?

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.)

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?

7 :
A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

8 :
The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

9 :
An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

10 :
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

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LPN HESI Exit-2023 Exam 2

No.

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?

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.)

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?

7 : A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

8 : The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

9 : An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

10 : In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

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?

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.)

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?

7 :
A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

8 :
The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

9 :
An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

10 :
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?