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 young adult client was admitted 36 hours ago for a head injury that occurred as a result of a motorcycle accident. In the last 4 hours, the client’s urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?
- A. Obtain capillary blood samples for glucose every 2 hours
- B. Measure oral secretions suctioned during the last 4 hours
- C. Evaluate the urine osmolality and serum osmolality values
- D. Obtain blood pressure and assess for dependent edema
Correct answer: C
Rationale: The correct answer is to evaluate the urine osmolality and serum osmolality values. The increased urine output following a head injury could indicate diabetes insipidus, a condition characterized by excessive urination and extreme thirst. Evaluating osmolality is crucial for diagnosing diabetes insipidus. Choice A is incorrect because obtaining capillary blood samples for glucose every 2 hours is not the priority in this situation. Choice B is irrelevant to the client's current symptom of increased urine output. Choice D is also not the most appropriate intervention as the focus should be on assessing for a potential endocrine issue related to the increased urine output.
3. 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.
4. The healthcare provider changes a client’s medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduces bioavailability. What action should the nurse implement?
- A. Continue administering the medication via the IV route.
- B. Give half the prescribed oral dose until consulting the provider.
- C. Administer the medication orally as prescribed.
- D. Consult with the pharmacist regarding the prescription change.
Correct answer: D
Rationale: The correct action for the nurse to implement is to consult with the pharmacist regarding the change in prescription. With the high first-pass effect of the medication when given orally, it reduces its bioavailability, meaning a dosage adjustment may be necessary to achieve the desired therapeutic effect. Continuing to administer the medication via the IV route (choice A) is not appropriate as the prescription has been changed to oral administration. Giving half the prescribed oral dose until consulting the provider (choice B) is not recommended without proper guidance, which should come from consulting with the pharmacist. Simply administering the medication orally as prescribed (choice C) without addressing the potential issue of reduced bioavailability may lead to suboptimal treatment outcomes.
5. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which finding?
- A. Restlessness
- B. Clenched Fist
- C. Increased pulse rate
- D. Increased respiratory rate
Correct answer: A
Rationale: In infants, restlessness can be a significant indicator of discomfort or pain, necessitating appropriate pain management. While choices B, C, and D can also be associated with pain, restlessness is a more general and reliable indicator in this scenario. A clenched fist might indicate pain or distress, but it is not as specific as restlessness in assessing pain in infants. Increased pulse rate and respiratory rate can be influenced by various factors other than pain, making them less reliable indicators of pain in this context.
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