HESI LPN
CAT Exam Practice
1. The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father's plan of care?
- A. Use of bedrest with scrotal support
- B. Administration of antibiotics for 10 days
- C. Applying heat to promote the healing process
- D. Using an ice pack to reduce scrotal pain
Correct answer: A
Rationale: For orchitis, the recommended intervention is bedrest with scrotal support. This helps reduce swelling and discomfort in the scrotum. Antibiotics are generally not required for viral orchitis, so administering antibiotics for 10 days (Choice B) is not indicated. Applying heat (Choice C) may worsen swelling and should be avoided. Using an ice pack (Choice D) is not the preferred method for managing orchitis; it may not be as effective as providing support and rest for the scrotum.
2. 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.
3. Which situation is a violation of client confidentiality, as described in the Health Insurance Portability and Accountability Act (HIPAA)?
- A. A sign-in sheet kept at the front desk listing clients' last names and the time of their arrival
- B. A nurse's handwritten notes from a telephone report discarded in the office wastebasket
- C. A computer monitor screen located at the nurse's station in a high-traffic area
- D. Privileged Health Information (PHI) given to an ambulance driver for the transfer of a client
Correct answer: C
Rationale: Choice C is a violation of client confidentiality as it exposes patient information to unauthorized individuals due to its location in a high-traffic area. HIPAA regulations require that electronic protected health information (ePHI) be safeguarded against unauthorized access, making the situation described in choice C a violation. Choices A, B, and D do not directly involve the exposure of patient information to unauthorized individuals. While choices A and B may pose some risks, they are not as severe as the direct exposure described in choice C. Choice D involves sharing information with an ambulance driver for a legitimate purpose, which does not violate HIPAA if done securely and in compliance with regulations.
4. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “What do you think you’re doing?†How should the nurse respond?
- A. “I cannot give you this medication until you calm down.â€
- B. “This shot will help relieve the pain in your feet.â€
- C. “Would you prefer to learn to administer your own shot?â€
- D. “You will feel calmer and less jittery after this shot.â€
Correct answer: B
Rationale: The correct response is to provide a relevant explanation to the client. Choice B, “This shot will help relieve the pain in your feet,†is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.
5. A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
- A. Administer the infusion via an infusion pump
- B. Obtain the current serum potassium level
- C. Continuously monitor blood pressure
- D. Teach guided imagery to decrease pain
Correct answer: C
Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99