HESI LPN
HESI CAT Exam 2022
1. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client’s statements?
- A. Remind the client that it is also important to schedule an annual mammogram.
- B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure.
- C. Encourage the client to perform BSE 2 to 3 days after her menstrual period ends.
- D. Instruct the client to continue with her regular monthly exams as she is doing.
Correct answer: C
Rationale: The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.
2. To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?
- A. Verify the feeding tube position with a daily chest x-ray
- B. Maintain head of bed elevated while enteral feeding is infusing
- C. Check feeding tube placement with air bolus prior to use
- D. Aspirate stomach contents every 4 hours to assess residuals
Correct answer: B
Rationale: The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.
3. A client is admitted with pyelonephritis, and cultures reveal an Escherichia coli infection. The client is allergic to penicillins, and the healthcare provider prescribed vancomycin IV. The nurse should plan to carefully monitor the client for which finding during IV administration?
- A. Tissue sloughing upon extravasation
- B. Elevated blood pressure and heart rate
- C. Tinnitus and vertigo
- D. Erythema of the face, neck, and chest
Correct answer: C
Rationale: The correct answer is C: Tinnitus and vertigo. Vancomycin can cause ototoxicity and nephrotoxicity, leading to symptoms like tinnitus and vertigo. Monitoring for these adverse effects is crucial to prevent further complications. Choices A, B, and D are incorrect because tissue sloughing, elevated blood pressure and heart rate, and erythema of the face, neck, and chest are not typically associated with vancomycin administration. Therefore, the nurse should focus on monitoring for signs of ototoxicity and nephrotoxicity such as tinnitus and vertigo.
4. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)
- A. Take out dentures and place them in a labeled cup
- B. Apply a body shroud
- C. Place a small pillow under the head
- D. Gently close the eyes
Correct answer: A
Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.
5. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?
- A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
- B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
- C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
- D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.
Correct answer: C
Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.
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