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. 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. A premature infant weighing 1,200 grams at birth receives a prescription for beractant (Survanta) 120 mg endotracheal now and q6 hr for 24 hr. The recommended dose for beractant is 100 mg/kg birth weight per dose. Single-use vials of Survanta are labeled 100 mg/4 ml. What action should the nurse take?
- A. Give 4.8 ml q6 hr
- B. Notify the healthcare provider that the dose is too high
- C. Notify the healthcare provider that the dose is too low
- D. Give 1.2 ml q6 hr
Correct answer: A
Rationale: The correct answer is to give 4.8 ml q6 hr. To calculate the dose, you divide the prescribed dose of 120 mg by the concentration of Survanta, which is 100 mg per 4 ml. This results in 4.8 ml per dose, as 120 mg รท 100 mg/4 ml = 4.8 ml. Option B suggesting to notify the healthcare provider that the dose is too high is incorrect because the calculated dose of 4.8 ml is based on the recommended dose of 100 mg/kg birth weight. Option C suggesting to notify the healthcare provider that the dose is too low is incorrect as the calculated dose is based on the correct dosage calculation. Option D suggesting to give 1.2 ml q6 hr is incorrect because it doesn't align with the correct calculation.
5. When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.
- A. Breast screening for older women
- B. Rehabilitation services for stroke victims
- C. Blood pressure assessments
- D. Antepartum nutritional counseling
Correct answer: A
Rationale: The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.
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