HESI LPN
HESI CAT Exam 2022
1. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)
- A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)
- B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
- D. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative
Correct answer: B
Rationale: The correct answer is B. Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a task within the scope of practice for a practical nurse (PN) and contributes to the client's recovery. Administering insulin (Choice A) involves medication administration, which typically requires a higher level of nursing education. Performing daily surgical dressing changes (Choice C) after an abdominal hysterectomy involves wound care management that is usually beyond the scope of practice for a PN. Initiating patient-controlled analgesia pumps (Choice D) is a complex nursing intervention that requires specialized training and knowledge, exceeding the typical responsibilities of a PN.
2. Which intervention should the nurse include in the plan of care for a patient with tetanus?
- A. Open window shades to provide natural light
- B. Encourage coughing and deep breathing
- C. Minimize the amount of stimuli in the room
- D. Reposition from side to side every hour
Correct answer: C
Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (Choice A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (Choice B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (Choice D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.
3. An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority?
- A. Self-care deficit
- B. Disturbed sleep pattern
- C. Disturbed thought processes
- D. Imbalanced nutrition
Correct answer: D
Rationale: Imbalanced nutrition is the priority in this case as the patient has lost a significant amount of weight and is neglecting self-care, such as bathing and eating properly. The weight loss indicates a serious issue that needs immediate attention to prevent further health complications. While self-care deficit, disturbed sleep pattern, and disturbed thought processes are also concerns for this patient, addressing the imbalanced nutrition takes precedence due to the potential impact on the patient's physical health. Neglecting proper nutrition can lead to serious complications, so it is crucial to address this issue first.
4. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?
- A. Notify the healthcare provider
- B. Limit the client’s fluids
- C. Prepare the client for an echocardiogram
- D. Document in the client’s record
Correct answer: D
Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.
5. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?
- A. Monitor signs of increased bleeding
- B. Instruct on the use of incentive spirometry
- C. Observe for confusion and restlessness
- D. Administer intravenous opioids for severe pain
Correct answer: A
Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.
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