HESI LPN
HESI CAT Exam
1. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?
- A. Clients who developed disease complications promptly received rehabilitation
- B. More than 50% of at-risk clients were diagnosed early in their disease process
- C. Only 30% of clients did not attend self-management education sessions
- D. Average client scores improved on a specific risk factor knowledge test
Correct answer: A
Rationale: The correct answer is A because in tertiary prevention, the focus is on managing complications and providing rehabilitation. Choice B is more aligned with primary prevention as it focuses on early diagnosis. Choice C's attendance in education sessions is not a direct indicator of managing complications. Choice D's improvement in knowledge does not directly measure the program's effectiveness in managing complications.
2. A client has a history of vasovagal attacks resulting in brady-dysrhythmias. Which instruction is most important to include in the teaching plan?
- A. Use stool softeners regularly
- B. Avoid electromagnetic fields
- C. Maintain a low-fat diet
- D. Do not use aspirin products
Correct answer: A
Rationale: The correct answer is A: 'Use stool softeners regularly.' Vasovagal attacks can be triggered by straining, and using stool softeners can help prevent such attacks. Choices B, C, and D are not directly related to preventing vasovagal attacks in this context. Avoiding electromagnetic fields, maintaining a low-fat diet, or not using aspirin products are important for various health reasons but not specifically for preventing vasovagal attacks related to brady-dysrhythmias.
3. A 9-year-old received a short arm cast for a right radius. To relieve itching under the child’s cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct answer: A
Rationale: Blowing cool air from a hair dryer under the cast is a safe method to relieve itching without damaging the cast or causing injury. The air helps to dry out the moisture that is causing the itching. Twisting the cast back and forth (choice B) can create pressure points and discomfort for the child. Shaking powder into the cast (choice C) can introduce foreign material that may cause skin irritation. Pushing a pencil under the cast edge (choice D) can injure the child's skin or even dislodge the cast.
4. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.
- A. Observe for an intradermal bleed after the antigen is injected
- B. Select an ID site using the volar surface of the forearm
- C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
- D. Ensure that the needle is inserted into the skin with the bevel up
Correct answer: A
Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.
5. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. What action should the nurse implement?
- A. Palpate the client’s suprapubic area for distention
- B. Advise the client to maintain a voiding diary for one week
- C. Instruct the client in effective techniques for cleansing the glans penis
- D. Obtain a urine specimen for culture and sensitivity
Correct answer: B
Rationale: Advising the client to maintain a voiding diary is the appropriate action in this case. A voiding diary helps track symptoms and patterns essential for diagnosing conditions like benign prostatic hyperplasia or other urinary issues. Palpating the client’s suprapubic area for distention (Choice A) may provide information about bladder fullness but does not address the need for tracking symptoms. Instructing the client in techniques for cleansing the glans penis (Choice C) is not relevant to the client's urinary complaints. Obtaining a urine specimen for culture and sensitivity (Choice D) may be necessary but does not directly address the client's symptoms of weak urine flow and difficulty initiating the urine stream.
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