HESI LPN
HESI CAT Exam Quizlet
1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. The client is experiencing difficulty breathing and is very anxious. The nurse notes that the client’s oxygen saturation is 88% on room air. Which action should the nurse implement first?
- A. Place the client in a high Fowler’s position
- B. Administer supplemental oxygen
- C. Perform a thorough respiratory assessment
- D. Start an IV infusion of normal saline
Correct answer: B
Rationale: Administering supplemental oxygen is the first priority to address low oxygen saturation and ease breathing. In a client with COPD experiencing difficulty breathing and anxiety with oxygen saturation at 88%, providing supplemental oxygen takes precedence over other actions. Placing the client in a high Fowler’s position may help with breathing but does not address the immediate need for increased oxygenation. Performing a thorough respiratory assessment is important but should come after stabilizing the client's oxygen levels. Starting an IV infusion of normal saline is not the priority in this situation and does not directly address the client's respiratory distress.
2. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?
- A. Urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours.
- B. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle.
- C. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens.
- D. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours.
Correct answer: A
Rationale: The correct instruction for the adult male client to follow when collecting a 24-hour urine specimen for a creatinine clearance test is to urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours. This method ensures proper collection for an accurate creatinine clearance measurement. Choice B is incorrect as it describes a different procedure for a clean-catch urine sample, not suitable for creatinine clearance. Choice C is incorrect as it suggests catheterization, which is not typically done for a creatinine clearance test, and it is not necessary for this procedure. Choice D is incorrect as it does not follow the standard procedure for a 24-hour urine collection for creatinine clearance; the urine should be collected continuously over 24 hours, not at specified intervals.
3. An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse?
- A. Reports a tearing, sharp pain between his shoulder blades
- B. Blood pressure reading of 200/100 mmHg 15 minutes later
- C. Rose-colored urine draining from the urinary catheter
- D. Sinus tachycardia with frequent premature ventricular beats (PVC)
Correct answer: A
Rationale: A tearing, sharp pain between the shoulder blades may indicate aortic dissection, a serious complication requiring immediate intervention. This symptom is highly concerning in a patient with a thoracic aneurysm. Choice B is not as urgent as the pain symptom described in choice A. Choice C could indicate hematuria but is not as critical as the potential aortic dissection in choice A. Choice D, sinus tachycardia with PVCs, may be related to the patient's condition but is not as indicative of an immediate life-threatening situation as the tearing, sharp pain indicative of aortic dissection.
4. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?
- A. Administer an anxiolytic
- B. Obtain a 12-lead electrocardiogram
- C. Stop the albuterol administration and restart in 30 minutes
- D. Educate the client about the side effects of albuterol
Correct answer: D
Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.
5. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?
- A. Headache
- B. Pruritus
- C. Nausea
- D. Stridor
Correct answer: D
Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.
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