HESI LPN
HESI CAT Exam Quizlet
1. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion, and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?
- A. Restrict daily fluid intake
- B. Eat meals at the same time daily
- C. Maintain a low-protein diet
- D. Limit the intake of high-calorie foods
Correct answer: A
Rationale: Dependent edema in both lower legs is a sign of fluid overload, which can exacerbate dyspnea in patients with COPD. Restricting daily fluid intake can help reduce the edema and alleviate breathing difficulties. A low-protein diet is not necessary unless there are specific renal concerns. Eating meals at the same time daily or limiting high-calorie foods is not directly associated with addressing fluid overload and dyspnea in COPD patients.
2. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever?
- A. Thrombocytopenia
- B. Polycythemia
- C. Decreased ESR
- D. Positive ASO titer
Correct answer: D
Rationale: The correct answer is D: Positive ASO titer. A positive ASO titer indicates recent streptococcal infection, which is associated with acute rheumatic fever. Thrombocytopenia (choice A) is not a typical laboratory finding in acute rheumatic fever. Polycythemia (choice B) refers to an increased red blood cell count, which is not typically seen in acute rheumatic fever. Decreased ESR (choice C) is not a common laboratory finding in acute rheumatic fever; in fact, ESR is often elevated in inflammatory conditions like rheumatic fever.
3. 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.
4. 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.
5. Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?
- A. Bulk-forming agent
- B. Antianxiety agent
- C. Stool softener
- D. Stimulant cathartic
Correct answer: C
Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (Choice A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (Choice B) would address the anxiety but not the physical discomfort. Stimulant cathartics (Choice D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.
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