HESI LPN
HESI CAT Exam
1. What nursing intervention is particularly indicated for the second stage of labor?
- A. Providing pain medication to increase the client’s tolerance of labor
- B. Assessing the fetal heart rate and pattern for signs of fetal distress
- C. Monitoring effects of oxytocin administration to help achieve cervical dilation
- D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved
Correct answer: D
Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.
2. The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?
- A. The appearance of the returning dialysate fluid is cloudy
- B. The client complains of slight shortness of breath during installation
- C. The amount of the returning dialysate fluid is greater than the amount instilled
- D. The client complains of abdominal fullness and cramping during instillation
Correct answer: A
Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.
3. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome?
- A. Lorazepam (Ativan)
- B. Famotidine (Pepcid)
- C. Thiamine (Vitamin B1)
- D. Atenolol (Tenormin)
Correct answer: C
Rationale: Thiamine supplementation is critical in preventing Wernicke's syndrome, especially in clients with chronic alcohol use. Wernicke's syndrome is a neurological disorder caused by thiamine deficiency. Lorazepam is a benzodiazepine used for anxiety and not for preventing Wernicke's syndrome. Famotidine is an H2 blocker used to reduce stomach acid production but does not prevent Wernicke's syndrome. Atenolol is a beta-blocker used for hypertension and angina, not for preventing Wernicke's syndrome.
4. The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first?
- A. Continue to monitor intake and output with the next exchange
- B. Check the client's blood pressure and serum bicarbonate levels
- C. Irrigate the dialysis catheter
- D. Change the client's position
Correct answer: D
Rationale: In this situation, the priority action for the nurse is to change the client's position. Altering the client's position can help facilitate better fluid drainage in peritoneal dialysis, potentially resolving the issue without the need for more invasive interventions. Continuing to monitor intake and output (Choice A) is important but addressing the immediate drainage issue takes precedence. Checking blood pressure and serum bicarbonate levels (Choice B) is not directly related to the observed output flow discrepancy. Irrigating the dialysis catheter (Choice C) should not be the initial action as it is more invasive and should be considered only if repositioning does not resolve the issue.
5. After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol’s effectiveness?
- A. Compare the number of falls that occurred before and after protocol implementation
- B. Analyze data that reflects the unit’s costs incurred due to the new protocol
- C. Conduct a chart review on the unit to determine the number of clients at risk for falling
- D. Consult with the physical therapist to evaluate the benefits of the new fall protocol
Correct answer: A
Rationale: The best way to evaluate the effectiveness of a new fall prevention protocol is by comparing the number of falls that occurred before and after its implementation. This direct comparison helps in assessing the impact of the protocol on reducing fall rates. Choices B, C, and D do not directly measure the effectiveness of the protocol. Analyzing costs incurred (Choice B), conducting a chart review (Choice C), or consulting with a physical therapist (Choice D) may provide valuable information but do not specifically evaluate the protocol's effectiveness in preventing falls.
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