HESI LPN
CAT Exam Practice
1. When educating a group of school-age children on reducing the risk of Lyme disease, which instruction should the camp nurse include?
- A. Wash hands frequently
- B. Avoid drinking lake water
- C. Wear long sleeves and pants
- D. Do not share personal products
Correct answer: C
Rationale: The correct instruction to reduce the risk of Lyme disease is to wear long sleeves and pants. This helps prevent tick bites, which are the primary mode of transmission for Lyme disease. Wearing protective clothing reduces the skin's exposure to ticks, decreasing the chances of getting bitten. Washing hands frequently (Choice A) is important for general hygiene but not specifically for preventing Lyme disease. Avoiding drinking lake water (Choice B) is unrelated to the prevention of Lyme disease. Not sharing personal products (Choice D) is important for preventing the spread of infections but does not directly reduce the risk of Lyme disease.
2. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?
- A. Monitor the client’s cardiac activity via telemetry.
- B. Maintain venous access with an infusion of normal saline.
- C. Assess glucose levels via finger stick every 4 to 6 hours.
- D. Evaluate hourly urine output for the return of normal renal function.
Correct answer: A
Rationale: Monitoring cardiac activity is crucial in this scenario because hyperkalemia can lead to serious cardiac dysrhythmias, which can be life-threatening. Regular monitoring of the client’s cardiac activity via telemetry allows for early detection of any potential cardiac complications. Maintaining venous access with a normal saline infusion is important for hydration but does not address the immediate risk of cardiac dysrhythmias posed by hyperkalemia. Assessing glucose levels is essential in diabetes management but is not the priority when dealing with hyperkalemia-induced cardiac risks. Evaluating hourly urine output for the return of normal renal function is important in ARF but is not as urgent as monitoring the client's cardiac activity in the context of hyperkalemia.
3. A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?
- A. Fetal heart tones located in the upper right quadrant
- B. Biophysical profile results showing oligohydramnios
- C. Regular contractions occurring every 10 minutes
- D. Sterile vaginal exam revealing 3 cm dilation
Correct answer: B
Rationale: Oligohydramnios (low amniotic fluid) is a significant concern before starting oxytocin and should be reported to ensure safe labor induction. This finding can indicate potential fetal compromise and requires immediate evaluation. Fetal heart tones located in a specific quadrant, regular contractions, and cervical dilation are common assessments during labor but are not as critical as oligohydramnios in this scenario.
4. In what order should the nurse assess a lethargic one-hour-old infant brought to the nursery?
- A. Heel stick
- B. Respirations
- C. Heart rate
- D. Temperature
Correct answer: D
Rationale: When assessing a lethargic one-hour-old infant, the nurse should prioritize assessing the most critical parameters first. Temperature and heart rate are vital signs that provide immediate information about the infant's well-being. Therefore, the correct order of assessment should be temperature, heart rate, respirations, and then a heel stick. Temperature is crucial to determine if the infant is hypothermic or hyperthermic, while heart rate gives insight into the circulatory system's function. Respirations follow to evaluate the infant's breathing pattern. Lastly, the heel stick is important for certain screenings but is not as urgent as evaluating temperature and heart rate in a lethargic infant.
5. Which type of wound would most likely require immediate intervention by the healthcare provider?
- A. Laceration
- B. Abrasion
- C. Contusion
- D. Ulceration
Correct answer: A
Rationale: A laceration would most likely require immediate intervention by the healthcare provider due to its deeper tissue damage, significant bleeding, and higher risk of infection compared to abrasions, contusions, and ulcerations. Lacerations often need prompt attention to control bleeding, clean the wound, and reduce the risk of infection. Abrasions are superficial wounds that usually do not require urgent attention as they tend to heal well on their own with basic wound care. Contusions are bruises that typically resolve on their own without immediate intervention. Ulcerations are open sores that may require intervention but not necessarily immediate action unless complicated by infection or other issues.
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