HESI LPN
HESI CAT Exam 2022
1. When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?
- A. Lactate
- B. Glucose
- C. Hemoglobin
- D. Creatinine
Correct answer: B
Rationale: When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.
2. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and weak, thread pedal pulses. What action should the nurse take?
- A. Document that an accurate oxygen saturation reading cannot be obtained
- B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger
- C. Increase the oxygen based on the client's breathing patterns and lung sounds
- D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading
Correct answer: D
Rationale: Placing the oximeter clip on the earlobe is appropriate for clients with poor peripheral circulation, such as those with weak and thread pedal pulses due to bilateral below-the-knee amputations. This placement can provide a more accurate reading of oxygen saturation in such clients. Choice A is incorrect because alternative methods, such as earlobe placement, can be used to obtain accurate readings. Choice B is unnecessary and not related to obtaining an accurate oxygen saturation reading. Choice C is incorrect because increasing oxygen without assessing the oxygen saturation level first can be detrimental and is not based on evidence-based practice.
3. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?
- A. Verbalizes a fear of being in a confined space.
- B. Drank a glass of water in the past 2 hours.
- C. Reports left chest wall pain prior to admission.
- D. Experiences facial swelling after eating crab
Correct answer: C
Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.
4. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Ensure that the knot can be quickly released.
- B. Tie the knot with a double turn or square knot.
- C. Move the ties so the restraints are secured to the side rails.
- D. Ensure that the restraints are snug against the client's wrist.
Correct answer: A
Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.
5. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse to report to the healthcare provider?
- A. Decreased white blood cell count
- B. Pruritus and muscle aches
- C. Elevated liver function tests
- D. Vomiting and diarrhea
Correct answer: C
Rationale: The correct answer is C: Elevated liver function tests. When administering antivirals, especially orally, monitoring liver function tests is crucial as it may indicate liver toxicity. This finding should be reported promptly to the healthcare provider to prevent further complications. Choice A, decreased white blood cell count, may be expected with certain antivirals but is not the most critical finding in this scenario. Pruritus and muscle aches (choice B) are common side effects of antivirals and do not require immediate reporting. Vomiting and diarrhea (choice D) are also common side effects that may not be as concerning as elevated liver function tests.
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