HESI PN Exit Exam

Correct Answer: B

Rationale: A tea party in the courtyard is the most suitable activity as it allows for social interaction in a comfortable and accessible environment. Wheelchair-bound residents can easily participate, fostering both physical and social engagement. An open-air concert may pose challenges regarding accessibility and comfort for wheelchair-bound individuals. A team ring-toss competition involves physical activity that may not be inclusive for all residents, especially those in wheelchairs. A picnic in the park may also present challenges related to accessibility and comfort for wheelchair-bound individuals.

Correct Answer: D

Rationale: The correct answer is D: Protect skin from injury and bruising. Phenytoin and anticoagulants both increase the risk of bleeding. Protecting the skin from injury and bruising is critical to prevent complications, making it important to instruct the UAP accordingly. Measuring the temperature every 4 hours (Choice A) may not be directly related to the client's medications. Elevating both feet on two pillows (Choice B) is more relevant for issues like edema. Initiating an hourly turning schedule (Choice C) is important for preventing pressure ulcers, but in this case, the priority is to prevent bleeding due to the medications.

Correct Answer: B

Rationale: In this scenario, the correct action is to lay the client flat and notify the healthcare provider. A severe headache in a post-operative spinal fusion patient can indicate a spinal fluid leak, which is a medical emergency. By laying the client flat, the nurse helps reduce symptoms by decreasing pressure differentials. Administering pain medication without further assessment or intervention is inappropriate before identifying the cause of the headache. Encouraging the client to drink more fluids is not the priority when a serious complication like a spinal fluid leak is suspected. While assessing the surgical site is important, it is not the priority when a potentially life-threatening complication is suspected.

Correct Answer: C

Rationale: When a patient on anticoagulant therapy experiences sudden, severe back pain, the priority nursing action is to assess for signs of internal bleeding. Severe back pain in this context could be indicative of internal bleeding, such as a retroperitoneal bleed, which is a critical condition requiring immediate attention. Administering pain medication or applying a cold compress may mask or delay the identification of a potentially life-threatening situation. Repositioning the patient for comfort is not the priority when internal bleeding needs to be ruled out.

Correct Answer: D

Rationale: Measuring vital signs is crucial in this situation as it helps to determine if the client is experiencing a physical health issue or if the symptoms are related to a mental health crisis, such as anxiety or agitation. The presence of diaphoresis and pacing may indicate physiological changes requiring immediate attention. Providing a drink high in electrolytes or persuading the client to lie down may not address the underlying cause of the symptoms. Simply observing the client during the shift without taking necessary actions to assess his physiological status may delay appropriate intervention.