HESI LPN
HESI CAT Exam Quizlet
1. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?
- A. Apply oxygen at 10 L per minute via mask
- B. Stop the oxytocin infusion
- C. Turn the client to the right lateral position
- D. Continue monitoring the progress of labor
Correct answer: C
Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.
2. 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.
3. 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.
4. 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.
5. 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.
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