HESI PN Exit Exam 2024

Correct Answer: C

Rationale: Auscultating bowel sounds is the best initial action in this situation. It helps the nurse assess bowel function before considering interventions like administering a laxative. Abdominal pain and bloating could be indicative of bowel motility issues, and auscultation can provide crucial information. Encouraging increased fluid intake can be beneficial in promoting bowel movement, but assessing bowel sounds is more immediate to evaluate the current status. Notifying the healthcare provider should be reserved for situations where immediate intervention is needed or if the condition worsens after assessment.

Correct Answer: C

Rationale: A dark purple stoma may indicate compromised blood flow to the stoma, which is an emergency. Immediate notification of the healthcare provider is necessary to prevent further complications. Simply documenting and monitoring the finding (Choice A) could lead to delays in addressing a potentially serious issue. Applying warm compresses to the stoma (Choice B) may not address the underlying cause of the dark purple color. Encouraging the client to ambulate (Choice D) is not the priority when a compromised blood flow to the stoma is suspected.

Correct Answer: B

Rationale: The correct answer is B. Avoiding driving at night is recommended for clients experiencing glare around lights due to diabetic retinopathy. This can help reduce the risk of accidents and visual discomfort. Making adjustments to the personal schedule to avoid nighttime driving is a practical approach to manage the glare. Choices A, C, and D are incorrect because covering eyes with compresses, exerting pressure on the inner canthus, or applying an eye shield are not effective strategies for managing glare associated with diabetic retinopathy.

Correct Answer: C

Rationale: The correct first action when obtaining an orthostatic vital sign measurement is to instruct the client to lie supine. This allows for establishing a baseline measurement of vital signs before any positional changes. Counting the client's radial pulse (Choice A) is a step that follows after the initial supine position to assess changes in pulse rate. Applying a blood pressure cuff (Choice B) and assisting the client to stand upright (Choice D) are actions that come later in the process after the baseline measurements are obtained in the supine position.

Correct Answer: B

Rationale: Monitoring gastric residual volumes helps to assess how well the client is tolerating the increased feeding rate. High residuals may indicate delayed gastric emptying, which could lead to complications like aspiration. This helps in adjusting the feeding plan as necessary. Daily weight (Choice A) is not the most appropriate parameter to evaluate tolerance to feeding rate changes. Bowel sounds (Choice C) and urinary/stool output (Choice D) are important assessments but do not directly indicate tolerance to enteral feeding rate changes.