HESI LPN
HESI CAT Exam Quizlet
1. What is the primary focus of postoperative nursing care for the client with colon trauma?
- A. Monitoring for elevated coagulation studies
- B. Observation for and prevention of fistulas
- C. Monitoring for signs of hyponatremia
- D. Observation for and prevention of infection
Correct answer: D
Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.
2. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rates the pain 5 on a pain scale of 0 to 10. The client’s blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)
- A. Administer the scheduled daily dose of lisinopril.
- B. Assess the client for postural hypotension.
- C. Notify the healthcare provider immediately.
- D. Provide a PRN dose of acetaminophen for the headache.
Correct answer: A
Rationale: In this scenario, the client's blood pressure of 142/89 is within an acceptable range for someone with a history of hypertension. The client's headache with a pain rating of 5 does not warrant an immediate notification to the healthcare provider. Administering the scheduled dose of lisinopril is appropriate to manage the client's hypertension. Assessing the client for postural hypotension is relevant due to the client's age and hypertension history. Providing a PRN dose of acetaminophen for the headache is not necessary at this point as the pain level is moderate and can be managed with other interventions.
3. 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.
4. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Pain scale rating of 9 on a 0-10 scale
- B. Last menstrual period was 7 weeks ago
- C. Reports white curdy vaginal discharge
- D. History of irritable bowel syndrome (IBS)
Correct answer: B
Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.
5. 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.
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