HESI LPN
HESI CAT Exam 2022
1. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?
- A. Obtain a fingerstick glucose reading
- B. Administer 15 grams of a fast-acting carbohydrate
- C. Perform a quick assessment of the client’s neuro status
- D. Provide a glass of milk and monitor the client’s symptoms
Correct answer: B
Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.
2. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?
- A. Rising titers identify the etiology of certain neuro-sensory birth defects
- B. The screen determines the risk for inherited anomalies in the newborn
- C. The test identifies the correct antibiotic to give the newborn for an infection
- D. Exposure to infections that can cross the placenta cause a positive antibody titer
Correct answer: D
Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.
3. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?
- A. The client has asymmetrical chest wall expansion
- B. The client complains of pain at the insertion site
- C. The client's chest x-ray indicates decreased pleural effusion
- D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26
Correct answer: A
Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.
4. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?
- A. Sluggish pupillary response to light
- B. Clear fluid leaking from the nose
- C. Complaint of severe headache
- D. Periorbital ecchymosis of the right eye
Correct answer: B
Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.
5. A nurse working on an endocrine unit should see which client first?
- A. An adolescent male with diabetes who is arguing about his insulin dose.
- B. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
- C. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour.
- D. A client taking corticosteroids who has become disoriented in the last two hours.
Correct answer: B
Rationale: The correct answer is B. The client with Addison’s disease and a blood sugar level of 62mg/dl (3.44 mmol/l) is experiencing hypoglycemia, which can progress to adrenal crisis. This situation requires immediate attention to prevent further complications. Choices A, C, and D, although concerning, do not pose an immediate life-threatening risk compared to the client with Addison’s disease and hypoglycemia. The adolescent arguing about his insulin dose can be addressed after stabilizing the client with Addison’s disease. The adult with high blood sugar and increased urine output may have hyperglycemia but is not in immediate danger. The client taking corticosteroids who is disoriented needs evaluation but is not in an acute life-threatening condition as the client with hypoglycemia.
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