HESI LPN
HESI CAT Exam 2022
1. 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.
2. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?
- A. Obtain a fingerstick glucose reading
- B. Administer 15 grams of a fast-acting carbohydrate
- C. Perform a quick assessment of the client’s neuro status
- D. Provide a glass of milk and monitor the client’s symptoms
Correct answer: B
Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.
3. 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.
4. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
- A. Transport a client who is receiving IV fluid to the radiology department
- B. Administer PRN oral analgesics to a client with a history of chronic pain
- C. Supervise a newly hired graduate nurse during an admission assessment
- D. Complete ongoing focused assessments of a client with wrist restraints
Correct answer: C
Rationale: The correct answer is C because supervising a newly hired graduate nurse during an admission assessment is a task that falls within the registered nurse's scope of practice. Registered nurses are responsible for overseeing and delegating tasks, especially to new staff, to ensure proper assessment and care delivery. Choices A, B, and D involve tasks that can be appropriately assigned to practical nurses or unlicensed assistive personnel as they are within their scope of practice. Transporting a client, administering oral analgesics, and completing focused assessments do not require the advanced knowledge and skills of a registered nurse.
5. A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client?
- A. Take a prescribed analgesic and expose breasts to air
- B. Place warm packs on both breasts
- C. Avoid stimulation of the breasts and wear a tight bra
- D. Express a small amount of breast milk by hand
Correct answer: C
Rationale: For a postpartum client who is bottle feeding and develops breast engorgement, the best recommendation is to avoid stimulation of the breasts and wear a tight bra. This helps reduce engorgement by decreasing blood flow to the breasts. Option A is incorrect because exposing the breasts to air can further stimulate them, worsening engorgement. Option B is incorrect as warm packs can increase blood flow and exacerbate engorgement. Option D is incorrect as expressing breast milk can lead to further stimulation and increased engorgement.
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