HESI LPN
HESI CAT Exam 2022
1. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?
- A. Verbalizes a fear of being in a confined space.
- B. Drank a glass of water in the past 2 hours.
- C. Reports left chest wall pain prior to admission.
- D. Experiences facial swelling after eating crab
Correct answer: C
Rationale: The correct answer is C. Left chest wall pain could indicate ongoing cardiac issues or instability, which needs to be assessed before proceeding with the procedure. This pain could be related to the heart and may suggest a potential risk during the angioplasty. Options A, B, and D do not directly relate to cardiac complications during the procedure, making them less urgent for immediate assessment. Fear of confined spaces, drinking water, and facial swelling after eating crab are not immediate risks to the client's safety in the context of a cardiac catheterization procedure.
2. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Ensure that the knot can be quickly released.
- B. Tie the knot with a double turn or square knot.
- C. Move the ties so the restraints are secured to the side rails.
- D. Ensure that the restraints are snug against the client's wrist.
Correct answer: A
Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (Choice B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (Choice C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (Choice D) may not be appropriate if the restraints need to be quickly removed for the client's safety.
3. 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.
4. 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.
5. Parents who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide?
- A. All future children will be carriers, but will not necessarily have the disease
- B. There is a chance that each future child will have the disease
- C. Only male children cannot inherit the sickle cell disease trait
- D. Only one out of four of their children will definitely manifest the disease
Correct answer: B
Rationale: The correct answer is B. Each child has a 25% chance of having sickle cell anemia if both parents are carriers of the trait. Choice A is incorrect because not all future children will be carriers; some may have the disease. Choice C is incorrect as both male and female children can inherit the sickle cell disease trait. Choice D is incorrect as the chance is not fixed at one out of four; each child has an independent 25% chance of having the disease.
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