HESI LPN
HESI CAT Exam 2024
1. When the client asks the nurse if they have ever been with someone when they died, what is the nurse’s best response?
- A. “Yes, I have. Do you have some questions about dying?”
- B. “Several times. Now, let’s get your dressing changed.”
- C. “A few times. It was peaceful and there was no pain.”
- D. “Yes, but you’re doing great. Are you concerned about dying?”
Correct answer: A
Rationale: Choice A is the best response as it acknowledges the client's question and opens the door for further discussion about dying if the client wishes to. It shows empathy and encourages the client to express any concerns they may have. Choices B and C do not directly address the client's question or offer an opportunity for him to explore his concerns. Choice D acknowledges the experience but fails to address the client's question directly and does not encourage further discussion.
2. The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12-hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 ml, and voids twice. The dry diaper weighs 105 grams. Which computer documentation should the nurse enter in the infant’s record?
- A. Subtract vomitus from 120 ml Pedialyte, then document 95 ml oral intake.
- B. Compare the difference between the infant’s current weight and admission weight.
- C. Document on the flow sheet that the infant voided twice and vomited 25 ml.
- D. Calculate the difference in wet and dry diapers and document 80 ml urine.
Correct answer: C
Rationale: The correct answer is to document on the flow sheet that the infant voided twice and vomited 25 ml. This choice accurately reflects the need for accurate documentation of intake and output, essential for monitoring the infant's hydration status. Choice A is incorrect because the oral intake should not be calculated by subtracting vomitus from the oral intake. Choice B is incorrect because it does not address the specific documentation related to the infant's output. Choice D is incorrect as it focuses on calculating urine output based on diaper weight, which is not the primary concern in this scenario.
3. An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?
- A. Explain the importance of bathing or showering daily
- B. Encourage fluid intake of at least 2,000 ml daily
- C. Keep the legs covered as much as possible
- D. Apply emollient to the affected area at least twice daily
Correct answer: D
Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.
4. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
- A. Altered consciousness within the first 24 hours after injury
- B. Confusion immediately following the injury
- C. Headache that resolves quickly
- D. Brief loss of consciousness with a lucid interval
Correct answer: A
Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.
5. A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?
- A. Reassure the client that pre-surgery anxiety is a normal experience
- B. Explain the surgery in clear terms that the client can understand
- C. Call the surgeon back to clarify the information with the client
- D. Redirect the client’s thoughts by teaching relaxation techniques
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.
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