HESI LPN
HESI CAT Exam 2022
1. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?
- A. Sluggish pupillary response to light
- B. Clear fluid leaking from the nose
- C. Complaint of severe headache
- D. Periorbital ecchymosis of the right eye
Correct answer: B
Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.
2. 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.
3. What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?
- A. Enlarged and tender cervical lymph nodes
- B. Presence of low-grade fever and sore throat
- C. Recent history of recurrent pneumonia
- D. CD4 blood cell count of 300
Correct answer: C
Rationale: The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.
4. 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.
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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