HESI LPN
HESI CAT Exam 2024
1. To evaluate the medication’s effectiveness in a client with a respiratory tract infection, which laboratory values should the nurse monitor?
- A. White blood cell (WBC) count
- B. Sputum culture and sensitivity
- C. Droplet precautions
- D. Protective environment
Correct answer: A
Rationale: The correct answer is A: White blood cell (WBC) count. Monitoring the WBC count helps assess the overall response to infection and the effectiveness of the antibiotic. Sputum culture and sensitivity (choice B) are also important to confirm if the antibiotic is targeting the specific pathogen. Choices C and D, droplet precautions and protective environment, are not laboratory values but rather infection control measures that do not directly evaluate the medication's effectiveness in treating the infection.
2. An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as a result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?
- A. Provide additional light in the room to promote sensory stimulation
- B. Teach the client to turn his head from side to side for visual scanning
- C. Place a clock and calendar in the room to improve orientation
- D. Use hand and arm gestures to improve communication and comprehension
Correct answer: B
Rationale: Teaching the client to turn his head from side to side for visual scanning is essential in addressing unilateral neglect syndrome caused by a cerebrovascular accident. This action helps improve visual awareness and assists the client in overcoming the neglect of one side of the body. Providing additional light for sensory stimulation (Choice A) may not directly address the issue of unilateral neglect. Placing a clock and calendar in the room (Choice C) may be helpful for orientation but does not specifically target unilateral neglect. Using hand and arm gestures for communication (Choice D) may aid in communication but does not directly address the visual scanning deficits associated with unilateral neglect syndrome.
3. A male client who fell into the lake while fishing and was submerged for about 3 min was successfully resuscitated by his friends. He was brought to the Emergency Department for evaluation and was admitted for a 24-hour uneventful hospital stay. What follow-up instruction should the nurse give?
- A. Avoid smoke-filled environments
- B. Seek medical care promptly if a fever develops
- C. Increase oral fluids if a cough becomes productive
- D. Schedule frequent rest periods
Correct answer: B
Rationale: After being submerged in water, the client should be instructed to seek medical care promptly if a fever develops since complications may arise later. Choices A, C, and D are not directly related to the potential complications from submersion in water and are therefore incorrect. Avoiding smoke-filled environments, increasing oral fluids for a productive cough, and scheduling frequent rest periods are not the priority concerns in this scenario.
4. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?
- A. Administer regular insulin per sliding scale
- B. Cancel the client's dinner tray
- C. Give the client 4 ounces (120 mL) of orange juice
- D. Administer the next scheduled dose of metformin
Correct answer: A
Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.
5. A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client’s plan of care?
- A. Encourage speaking slowly and articulating words
- B. Sit upright and flex chin forward while swallowing
- C. Position a communication board at the bedside
- D. Provide feeding utensils with large grip handles
Correct answer: B
Rationale: The correct intervention for a client with ALS experiencing difficulty swallowing and articulating words is to sit upright and flex the chin forward while swallowing. This position helps manage dysphagia associated with ALS by facilitating the swallowing process. Encouraging speaking slowly and articulating words (Choice A) may be helpful for speech clarity but does not address the swallowing issue. Positioning a communication board (Choice C) would not directly address the swallowing difficulty. Providing feeding utensils with large grip handles (Choice D) is not the priority intervention for managing dysphagia in ALS.
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