HESI LPN
HESI CAT Exam 2024
1. What should be the school nurse's first action after being notified that Child A has bitten Child B on the arm, resulting in broken skin but no bleeding?
- A. Apply antibiotic cream to Child B’s arm immediately
- B. Determine if Child A has a history of Hepatitis C or HIV
- C. Determine the date of Child B’s latest tetanus booster
- D. Wash Child B’s arm thoroughly with soap and water
Correct answer: D
Rationale: The correct first action for the school nurse to take in this situation is to wash Child B’s arm thoroughly with soap and water. Washing the wound immediately is crucial to reduce the risk of infection from the bite. Applying antibiotic cream may come after cleaning the wound. Determining Child A's medical history or checking Child B's tetanus status is important but not the immediate priority when dealing with a bite wound.
2. A female client tells the clinic nurse that she has doubts about binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia?
- A. Ask the client to complete a food diary for the last 3 days
- B. Review the client’s lab data to determine her TSH, T3, and T4 levels
- C. Interview the client about her use of laxatives and diuretics
- D. Encourage the client to describe her daily exercise regimen
Correct answer: C
Rationale: Inquiring about laxative and diuretic use helps confirm bulimia as these are common behaviors associated with the disorder. Asking the client to complete a food diary (Choice A) may provide information on eating patterns but does not directly support the diagnosis of bulimia. Reviewing lab data (Choice B) for thyroid function is not specific to bulimia. Encouraging the client to describe her exercise regimen (Choice D) may be relevant for overall health assessment but does not specifically address bulimia symptoms.
3. 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.
4. 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.
5. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
- A. Review the heart rhythm on cardiac monitors
- B. Check urinary catheter for obstruction
- C. Auscultate bilateral breath sounds
- D. Give PRN dose of lorazepam (Ativan)
Correct answer: B
Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99