HESI LPN
HESI CAT Exam 2024
1. A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
- A. Distended, tortuous veins in the left hand
- B. The left radial pulse is 2+ bounding
- C. Auscultation of a thrill on the left forearm
- D. Assessment of a bruit on the left forearm
Correct answer: C
Rationale: Auscultation of a thrill on the left forearm is the correct observation indicating that the AV fistula is patent. A thrill is a palpable vibration or buzzing sensation felt over the fistula, indicating the presence of blood flow. Choices A, B, and D do not directly assess the patency of the fistula. Distended, tortuous veins in the left hand may indicate venous hypertension; a bounding radial pulse could suggest increased blood flow through an artery, but it does not confirm fistula patency; assessment of a bruit indicates turbulent blood flow, but it does not confirm patency.
2. A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client’s urine specific gravity is 1.035. What action should the nurse implement?
- A. Encourage popsicles and fluids of choice
- B. Evaluate postural blood pressure measurements
- C. Obtain a specimen for urinalysis
- D. Assess bowel sounds in all quadrants
Correct answer: A
Rationale: Encouraging fluids helps address dehydration and potentially high urine specific gravity, which is often related to inadequate fluid intake. In this scenario, the client may be at risk of dehydration due to the appendectomy and the high urine specific gravity. Encouraging popsicles and fluids of choice can help increase fluid intake and improve hydration status. The other options are not the priority at this time. Postural blood pressure measurements may be relevant for assessing fluid status but are not the immediate action needed. Obtaining a specimen for urinalysis and assessing bowel sounds are not the priority actions based on the client's condition.
3. A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?
- A. Granulating tissue in foot ulcer
- B. Full volume of pedal pulse
- C. Reduced level of pain
- D. Improved visual activity
Correct answer: C
Rationale: The correct answer is C: 'Reduced level of pain.' Pregabalin is used to manage neuropathic pain, so a reduction in pain indicates the medication's effectiveness in this case. Granulating tissue in a foot ulcer and the full volume of a pedal pulse are not direct indicators of pregabalin's effectiveness in managing neuropathic pain. Improved visual activity is not related to the effects of pregabalin in diabetic peripheral neuropathy.
4. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?
- A. Instruct the client to perform cough and deep breathing exercises
- B. Assess the client’s vital signs and respiratory effort
- C. Administer oxygen via nasal cannula according to the PNR protocol
- D. Document assessment findings in the client’s medical record
Correct answer: B
Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.
5. After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?
- A. Observe the aspiration site
- B. Assess body temperature
- C. Monitor skin elasticity
- D. Measure urinary output
Correct answer: A
Rationale: The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.
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