HESI LPN
HESI CAT Exam 2022
1. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?
- A. Assess IV site frequently for signs of extravasation
- B. Monitor capillary refill distal to the infusion site
- C. Apply a topical anesthetic at the infusion site for burning
- D. Explain that temporary burning at the IV site may occur
Correct answer: A
Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.
2. 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.
3. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?
- A. Wear a dosimeter film badge when in the client’s room
- B. Spend 30 minutes at the bedside when providing direct care
- C. Change the linens every day after assisting with a bed bath
- D. Use gloves to remove the applicator if it is dislodged in the bed
Correct answer: A
Rationale: The correct action for the nurse to implement when caring for a client with a radioactive Cesium-loaded vaginal applicator during brachytherapy is to wear a dosimeter film badge when in the client’s room. Wearing a dosimeter badge is essential to monitor radiation exposure and ensure the safety of healthcare providers. Choice B is incorrect as the duration is not specified and unnecessary. Choice C is incorrect as changing linens daily does not directly relate to radiation safety. Choice D is incorrect as using gloves to remove the applicator if dislodged is important but not the primary action to monitor radiation exposure.
4. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply).
- A. Practice relaxation exercises
- B. Limit fluids to avoid bladder distention
- C. Space activities to allow for rest periods
- D. Avoid persons with infections
Correct answer: A
Rationale: The correct instruction to include in the discharge plan for a client with MS to reduce symptom exacerbation is practicing relaxation exercises. Relaxation exercises can help manage MS symptoms by reducing stress. Limiting fluids to avoid bladder distention is not appropriate as adequate hydration is essential for overall health and helps prevent complications like urinary tract infections. While spacing activities to allow for rest periods can be beneficial for general well-being, it is not directly related to symptom exacerbation in MS. Avoiding persons with infections is important to prevent infections, but it is not specifically targeted at reducing MS symptom exacerbation.
5. The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?
- A. Debulk tumor to maintain patency of air passages
- B. Relieve empyema after pneumonectomy
- C. Prevent the formation of effusion fluid
- D. Remove fluid from the intrapleural space
Correct answer: C
Rationale: The correct answer is C. Pleurodesis is a procedure used to prevent the re-accumulation of pleural effusion by creating adhesion between the pleurae. This helps prevent the formation of effusion fluid. Choices A, B, and D are incorrect because pleurodesis is not performed to debulk tumors, relieve empyema after pneumonectomy, or remove fluid from the intrapleural space. Understanding the purpose of pleurodesis is essential in providing accurate patient education and care.
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