HESI LPN
HESI CAT Exam 2024
1. When lactulose (Cephulac) 30 ml QID is prescribed for a male client with advanced cirrhosis, and he complains that it causes diarrhea, what action should the nurse take in response to the client’s statement?
- A. Explain that diarrhea is expected, but the drug reduces ammonia levels
- B. Document that the client is non-compliant with his treatment plan
- C. Tell the client to be concerned about more significant side effects of this drug
- D. Obtain a prescription for loperamide (Imodium) 4mg PO PRN diarrhea
Correct answer: A
Rationale: The correct answer is A. Diarrhea is an expected side effect of lactulose when used to reduce ammonia levels in cirrhosis. It helps in decreasing the absorption of ammonia in the colon, thereby reducing its levels in the blood. Option B is incorrect because it is essential for the nurse to educate the client about the expected side effects of the medication rather than assuming non-compliance. Option C is incorrect as it instills unnecessary fear in the client by suggesting more significant side effects without addressing the current concern. Option D is incorrect as loperamide should not be given automatically for diarrhea caused by lactulose, as the diarrhea is a therapeutic effect of the medication in this context.
2. 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.
3. A client presents to the healthcare provider with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been using over-the-counter ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test should the nurse report to the healthcare provider?
- A. Sedimentation rate
- B. White blood cell count
- C. Anti–CCP antibodies
- D. Activated Clotting Time
Correct answer: A
Rationale: The correct answer is A: Sedimentation rate. Sedimentation rate, Anti–CCP antibodies, and C-reactive protein are commonly used laboratory tests to indicate inflammation and help diagnose rheumatoid arthritis. An elevated sedimentation rate is a nonspecific indicator of inflammation in the body, which is often seen in RA. White blood cell count is not specific for RA and is not typically significant in the diagnosis. Anti–CCP antibodies are specific to RA and are useful in confirming the diagnosis. Activated Clotting Time is not relevant to the diagnosis of rheumatoid arthritis as it is not specific to this condition.
4. 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.
5. A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client?
- A. Noncompliance with medication related to thought broadcasting
- B. Situational self-esteem disturbance secondary to schizophrenia
- C. Disturbed sensory perception related to auditory hallucinations
- D. Impaired environmental interpretation related to paranoid delusions
Correct answer: D
Rationale: The correct answer is D: Impaired environmental interpretation related to paranoid delusions. The client's belief about cameras watching and recording him is a manifestation of paranoid delusions, indicating a misinterpretation of the environment. Choice A is incorrect because thought broadcasting is not directly related to the client's belief about surveillance equipment. Choice B is incorrect as self-esteem disturbance is not the primary issue presented. Choice C is also incorrect as the client is not experiencing auditory hallucinations but rather paranoid delusions about surveillance.
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