HESI LPN
HESI CAT Exam Quizlet
1. While assessing an older client’s fall risk, the client tells the nurse that they live at home alone and have never fallen. What action should the nurse take?
- A. Place the client on a high fall risk protocol solely based on their age
- B. Continue to obtain the client data needed to complete the fall risk survey
- C. Inform the client about falls occurring more often at the hospital than at home
- D. Record a minimal risk for falls based on the client's statement alone
Correct answer: B
Rationale: The correct action for the nurse in this scenario is to continue obtaining client data to complete the fall risk survey. This approach will help in conducting a comprehensive assessment of the client's risk factors. Placing the client on a high fall risk protocol solely based on age without a thorough assessment is premature and can lead to unnecessary interventions. Informing the client about falls in the hospital does not address the client's individual risk factors and is not relevant to the current assessment. Recording a minimal risk for falls based only on the client's statement may overlook other potential risk factors that need to be evaluated.
2. 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.
3. In what order should the nurse perform the steps of a surgical hand scrub prior to entering the operating room?
- A. Rinse from the fingertips to the elbow
- B. Scrape under the nails with a nail pick
- C. Use a soapy brush to scrub the hands
- D. Cleanse the arm with a lathered brush
Correct answer: B
Rationale: The correct order for performing a surgical hand scrub is to first scrape under the nails with a nail pick, then scrub the hands using a soapy brush, cleanse the arms, and finally rinse. This sequence ensures thorough cleaning and minimizes the risk of contamination. Choice A is incorrect because rinsing should be the final step, not the first. Choice C is incorrect as scrubbing the hands comes after scraping under the nails. Choice D is incorrect as cleansing the arms should follow hand scrubbing, not precede it.
4. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?
- A. An adolescent who works part-time in a paint factory
- B. A 2-year-old who plays on aging outdoor playground equipment
- C. A 10-year-old who has Type 1 diabetes mellitus
- D. An 8-year-old who lives in a housing project
Correct answer: B
Rationale: Children playing on aging playground equipment are at higher risk of lead poisoning due to potential exposure from old paint. This is because deteriorating paint on older playground equipment may contain lead, which can be ingested by young children. Choices A, C, and D do not directly involve potential exposure to lead paint, making them less susceptible to lead poisoning compared to a child playing on aging playground equipment.
5. The mother of a school-age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse’s best response?
- A. When all live lice are eliminated by the treatment
- B. Two weeks after the last treatment
- C. As soon as the itching stops
- D. After the treatment kills all the live lice
Correct answer: D
Rationale: The correct answer is 'After the treatment kills all the live lice.' The child can return to school once all live lice are eliminated to prevent the spread of Pediculosis capitis. This is essential as live lice are highly contagious. Choices A, B, and C are incorrect. Waiting for the itching to stop or for an epidemic to subside does not ensure that all live lice are eradicated, which is crucial to prevent reinfestation and transmission.
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