HESI LPN
HESI CAT Exam 2022
1. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client’s B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
- A. Measure the client’s oxygen saturation before taking further action
- B. Administer a PRN dose of nitroglycerin (Nitrostat)
- C. Administer the dose of furosemide as scheduled
- D. Hold the dose of furosemide until contacting the healthcare provider
Correct answer: D
Rationale: Elevated BNP levels in a client with heart failure may indicate worsening heart failure. Therefore, the correct action for the nurse to take when encountering an elevated BNP before administering furosemide is to hold the dose and contact the healthcare provider for further guidance. This precaution is necessary to ensure the client's safety and prevent potential complications. Options A and B are incorrect as they do not address the issue of the elevated BNP, which is crucial in this situation. Option C is also incorrect because administering furosemide without consulting the healthcare provider could be harmful if the client's condition is deteriorating.
2. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hour?
- A. 18
- B. 27
- C. 36
- D. 45
Correct answer: D
Rationale: The infusion rate is calculated based on the concentration of lidocaine and the prescribed rate of infusion. First, convert lidocaine's weight to milligrams (2 grams = 2000 mg). Then, use the formula: (Total volume in ml * dose in mg) / 60 minutes. For this case, (500 ml * 2000 mg) / 60 minutes = 45 ml/hour. Therefore, the correct answer is D. Choices A, B, and C are incorrect as they do not reflect the accurate calculation based on the provided concentration and infusion rate.
3. When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?
- A. To reduce abdominal pressure on the diaphragm
- B. To promote retraction of the intercostal accessory muscles of respiration
- C. To promote bronchodilation and effective airway clearance
- D. To decrease pressure on the medullary center which stimulates breathing
Correct answer: A
Rationale: Elevating the head of the bed to 30 degrees is done to reduce abdominal pressure on the diaphragm, aiding in lung expansion and oxygenation. This position helps improve respiratory mechanics by allowing the diaphragm to move more effectively. Choice B is incorrect as elevating the head of the bed does not directly promote retraction of the intercostal accessory muscles of respiration. Choice C is incorrect because although elevating the head of the bed can assist with airway clearance, its primary purpose in ARDS is to decrease pressure on the diaphragm. Choice D is incorrect because reducing pressure on the medullary center is not the main goal of elevating the head of the bed; the focus is on enhancing lung function and oxygen exchange.
4. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?
- A. Check for any kinks or obstructions in the client’s Foley tubing
- B. Assess the client’s blood pressure every 15 minutes
- C. Administer a prescribed PRN dose of hydralazine (Apresoline)
- D. Educate the client on recognizing symptoms of dysreflexia
Correct answer: B
Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.
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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