HESI LPN
HESI CAT Exam Quizlet
1. 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.
2. The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client
- A. Whose discharge has been delayed because of a postoperative infection
- B. With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration
- C. Newly admitted with a head injury who requires frequent assessments
- D. Who is receiving IV heparin that is regulated based on protocol
Correct answer: A
Rationale: The correct answer is option A because this client is the most stable and requires less supervision. Assigning a client whose discharge has been delayed due to a postoperative infection to the newly graduate practical nurse would be appropriate during a busy day as they are likely to need routine care and monitoring rather than immediate intensive interventions. Option B involves a client with poorly controlled type 2 diabetes on a sliding scale for insulin administration, which requires close monitoring and prompt intervention, making it a less suitable assignment for a new graduate who may need more guidance. Option C, a newly admitted patient with a head injury requiring frequent assessments, would demand a higher level of vigilance and expertise, which may be challenging for a new graduate nurse to handle without adequate supervision. Option D, a patient receiving IV heparin regulated based on protocol, involves complex medication management that may be too advanced for a new graduate nurse without sufficient oversight.
3. Which behavior is most likely to result in a breach of client confidentiality?
- A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
- B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
- C. Nursing students on the same team discussing their assigned client’s conditions
- D. A registered nurse privately sharing personal feelings about a client with another nurse on the team
Correct answer: B
Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.
4. An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?
- A. 5
- B. 10
- C. 15
- D. 20
Correct answer: A
Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.
5. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?
- A. Observe the appearance of the stool
- B. Assess the client’s skin turgor
- C. Review the client’s laboratory values
- D. Auscultate the client’s bowel sounds
Correct answer: A
Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.
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