HESI LPN
CAT Exam Practice
1. What actions should the nurse take regarding an older adult male who had an abdominal cholecystectomy and has become increasingly confused and disoriented over the past 24 hours, found wandering into another client’s room and returned to his own room by the unlicensed assistive personnel (UAP)? (Select all that apply)
- A. Apply soft upper limb restraints and raise all four bed rails
- B. Report mental status change to the healthcare provider
- C. Assess the client’s breath sounds and oxygen saturation
- D. Assign the UAP to re-assess the client’s risk for falls
Correct answer: B
Rationale: In this situation, the appropriate action for the nurse to take is to report the mental status change to the healthcare provider. Confusion and disorientation post-surgery can be indicative of various factors, such as electrolyte imbalances or respiratory issues, necessitating comprehensive assessment by the healthcare team. Applying restraints and raising bed rails may not address the underlying cause of the confusion, and assigning the UAP to reassess the client's risk for falls does not directly address the cognitive changes observed.
2. Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope?
- A. Pedal pulses
- B. Breath sounds
- C. Oxygen saturation
- D. Blood pressure
Correct answer: D
Rationale: The correct answer is 'D: Blood pressure.' It is crucial to check the client's blood pressure before ambulating them, especially if they have a history of syncope. Monitoring blood pressure helps to prevent falls by ensuring that the client's blood pressure is stable enough to tolerate the activity. Choices A, B, and C are not as critical in this scenario. Checking pedal pulses, breath sounds, or oxygen saturation is important but not as crucial as assessing blood pressure when preparing to ambulate a client with a history of syncope.
3. During an admission assessment on an HIV positive client diagnosed with Pneumocystis carinii pneumonia (PCP), which symptoms should the nurse carefully observe the client for?
- A. Weight loss exceeding 10 percent of baseline body weight
- B. Altered mental status and tachypnea
- C. Creamy white patches in the oral cavity
- D. Normal ABGs with wet lung sounds in all lung fields
Correct answer: B
Rationale: The correct answer is B: Altered mental status and tachypnea. These symptoms are indicative of PCP and severe HIV progression. Weight loss exceeding 10 percent of baseline body weight (choice A) may be seen in HIV/AIDS but is not specific to PCP. Creamy white patches in the oral cavity (choice C) are characteristic of oral thrush, which is more commonly associated with Candida infections in HIV patients. Normal ABGs with wet lung sounds in all lung fields (choice D) would not be expected with PCP, as it typically presents with hypoxemia and diffuse bilateral infiltrates on chest imaging.
4. Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent?
- A. Validate the client's understanding of the surgical procedure to be conducted
- B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
- C. Ensure the client, not a family member, signs the surgical consent form
- D. Confirm that the surgical consent form is signed and included in the client's record
Correct answer: A
Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.
5. Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?
- A. Initiate cardiac telemetry monitoring
- B. Maintain continuous pulse oximetry
- C. Perform capillary glucose measurements
- D. Monitor serum creatinine levels
Correct answer: D
Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.
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