Practice Question
The 2-hour exam of a newborn delivered by cesarean section reveals nasal flaring, visible retractions, audible grunting, a dusky skin color. Current vital signs are axillary temperature 98.5 F (36.9 C), pulse 148 beats/minute, and respirations 67 breaths/minute. Which intervention should the nurse implement first?
Answer Choices:
Correct Answer:
Place a pulse oximeter on the infant's foot.
Rationale:
🔹 The newborn is showing respiratory distress (nasal flaring, retractions, grunting, tachypnea, dusky color).
🔹 The first step is to assess oxygenation using a pulse oximeter before implementing interventions or notifying the provider.
🔹 Oxygen saturation provides objective data to guide urgent care.
🔹 Bath delay and blood glucose are unrelated priorities.
🔹 Accurate SpO₂ determines the need for immediate oxygen therapy.
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This question is from Hesi -LPN -ADN Entrance 2025 Exam which contains 87 questions.
More Questions from This Exam
A client returns to the unit following a cardiac catheterization with a femoral artery access. Which objective criteria is most important for the practical nurse (PN) to obtain immediately upon the client's return?
Answer Choices:
A. Pupil responses to light.
B. Peripheral mobility.
C. Pedal pulses.
D. Respiratory rate.
Which serum lab test is most important for the nurse to monitor when administering enoxaparin to a client?
Answer Choices:
A. Protein and albumin.
B. BUN and creatinine.
C. Electrolytes.
D. Complete blood count (CBC).
A male client's temperature is 100.8° F (38.22° C) and he is beginning to exhibit signs of a urinary tract infection (UTI). The nurse is considering notifying the healthcare provider, but is feeling stressed about calling the healthcare provider who has previously been short-tempered with the nurse. Which action should the nurse take?
Answer Choices:
A. Observe the client carefully and wait until there are more definite signs of infection before calling the healthcare provider
B. Administer a PRN headache prescription which will also help decrease the client's temperature.
C. Call the healthcare provider, clearly state the purpose of the call, and provide the details of the client's condition.
D. Ask a nurse who has a better rapport with the healthcare provider to notify the healthcare provider of the client's condition
Which approach should the PN take in administering nystatin (oral) suspension to the gums of an infant with a candida infection?
Answer Choices:
A. Use a gloved finger to rub the suspension over the infected area.
B. Draw up the medication in a needle-less syringe which the infant can suck.
C. Irrigate the infected area with medicated solution after applying sterile gloves.
D. Measure the prescribed amount of solution into the infant's bottle.
When inserting a nasogastric tube, which action should the practical nurse (PN) perform first ?
Answer Choices:
A. Measure the client's nose-earlobe-xiphoid distance.
B. Auscultate the client's epigastric region for bowel sounds.
C. Lubricate the nasogastric tube with petroleum-based lubricant.
D. Affix the nasogastric tubing to low intermittent suction.
Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN HESI Exit Exam(s)
- Domain: LPN HESI Exit-2025
- Answer Choices: 4