HESI LPN
HESI CAT Exam Quizlet
1. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care?
- A. Perform fingerstick glucose assessment q6h with meals
- B. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose
- C. Review proper foot care and prevention of injury with the client
- D. Avoid contaminating the insulin aspart for IV use
Correct answer: A
Rationale: Performing fingerstick glucose assessments q6h with meals is essential in monitoring the client's blood glucose levels closely, especially when managing hyperglycemic episodes and adjusting insulin doses with a sliding scale. This action helps in determining the effectiveness of the prescribed insulin regimen. Reviewing proper foot care and preventing injury is important for long-term diabetic management but not the immediate priority in this scenario. Mixing insulin glargine with insulin aspart is not recommended, as they are different types of insulin with distinct mechanisms of action. Ensuring the availability of insulin aspart for IV use is not relevant to the client's current care plan.
2. To evaluate the client's therapeutic response to lactulose for signs of hepatic encephalopathy, which assessment should the nurse obtain?
- A. Level of consciousness
- B. Percussion of abdomen
- C. Serum electrolytes
- D. Blood glucose
Correct answer: A
Rationale: The correct answer is A: Level of consciousness. Monitoring the client's level of consciousness is essential in evaluating the effectiveness of lactulose in treating hepatic encephalopathy. Lactulose helps reduce blood ammonia levels by promoting the excretion of ammonia in the stool, thereby improving the client's mental status. Assessing the client's level of consciousness helps determine if the medication is effectively managing hepatic encephalopathy symptoms. Choices B, percussion of the abdomen, and D, blood glucose, are not directly related to evaluating the therapeutic response to lactulose for hepatic encephalopathy. Choice C, serum electrolytes, while important in overall patient care, is not the primary assessment to determine lactulose's effectiveness in treating hepatic encephalopathy.
3. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?
- A. Review the current treatment plan with the client
- B. Inform the healthcare provider about the client’s behaviors
- C. Determine if the client has PRN medication for anxiety
- D. Explore the client’s reasons for wanting to be discharged
Correct answer: D
Rationale: Exploring the client’s reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.
4. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent, and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, 'She says it is OK.' What action should the nurse take next?
- A. Clarify the client’s consent through the use of gestures and simple terms
- B. Have the interpreter co-sign the consent to validate the client's understanding
- C. Ask for a full explanation from the interpreter of the witnessed discussion
- D. Have the client sign the consent form and the nurse witness the signature
Correct answer: B
Rationale: Having the interpreter co-sign the consent form is the most appropriate action in this scenario. By having the interpreter co-sign, it ensures an additional layer of verification of the client's understanding and consent, which is crucial when language barriers exist. This step adds a level of confirmation to safeguard that the client's consent is both valid and well-informed. Option A is not sufficient as gestures and simple terms may not fully clarify the client's understanding, especially for complex medical procedures. Option C is unnecessary since the interpreter has already confirmed the client's consent. Option D does not involve the interpreter in validating the client's understanding, which is essential in this situation to ensure effective communication and comprehension between the client and the healthcare team.
5. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?
- A. The heart will stop beating, and you will stop breathing.
- B. You will go to sleep and not wake up.
- C. Your body will stop functioning, and you will no longer feel pain.
- D. You will feel very tired, and your body will shut down slowly.
Correct answer: C
Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.
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