HESI LPN
HESI CAT Exam 2022
1. The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?
- A. Current lab report indicates an Aptt at 1.5 times the client's control
- B. The client states that his right calf is aching and wants pain medication
- C. The spouse is assisting the client who is shaving with an electric razor
- D. Several bruised areas are noted on the client's upper extremities bilaterally
Correct answer: D
Rationale: The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.
2. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?
- A. Perform a finger stick glucose test
- B. Increase the IV fluid flow rate
- C. Review 24-hour intake and output
- D. Obtain arterial blood gases
Correct answer: A
Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.
3. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?
- A. Assess IV site frequently for signs of extravasation
- B. Monitor capillary refill distal to the infusion site
- C. Apply a topical anesthetic at the infusion site for burning
- D. Explain that temporary burning at the IV site may occur
Correct answer: A
Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.
4. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?
- A. Rising titers identify the etiology of certain neuro-sensory birth defects
- B. The screen determines the risk for inherited anomalies in the newborn
- C. The test identifies the correct antibiotic to give the newborn for an infection
- D. Exposure to infections that can cross the placenta cause a positive antibody titer
Correct answer: D
Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.
5. The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?
- A. Debulk tumor to maintain patency of air passages
- B. Relieve empyema after pneumonectomy
- C. Prevent the formation of effusion fluid
- D. Remove fluid from the intrapleural space
Correct answer: C
Rationale: The correct answer is C. Pleurodesis is a procedure used to prevent the re-accumulation of pleural effusion by creating adhesion between the pleurae. This helps prevent the formation of effusion fluid. Choices A, B, and D are incorrect because pleurodesis is not performed to debulk tumors, relieve empyema after pneumonectomy, or remove fluid from the intrapleural space. Understanding the purpose of pleurodesis is essential in providing accurate patient education and care.
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