HESI LPN
HESI CAT Exam Test Bank
1. The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?
- A. A 69-year-old widowed female who lives alone and volunteers at a school
- B. A 95-year-old ambulatory male who resides in a nursing home in a small town
- C. A 78-year-old female on a fixed income who lives with her relatives
- D. An 81-year-old male with diabetes who lives with his wife of 52 years
Correct answer: C
Rationale: Elder abuse risk is higher in individuals who live with relatives and are on a fixed income as these factors can contribute to vulnerability. Living with relatives may expose the individual to potential abusive situations within the family dynamics. Additionally, being on a fixed income may limit financial independence and increase dependency on others, potentially leading to financial abuse. The other options, such as living alone and volunteering, residing in a nursing home, or living with a long-term spouse, do not inherently pose the same level of risk factors for elder abuse as living with relatives on a fixed income.
2. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
- A. An older client receiving packed RBCs on the third day postoperatively for colon resection
- B. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery
- C. An adult one day postoperatively from laparoscopic cholecystectomy requesting pain medication
- D. An adult in Buck’s traction, scheduled for hip arthroplasty within the next 12 hours
Correct answer: B
Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.
3. The charge nurse of a cardiac telemetry unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client should be assigned to the RN?
- A. One day after a permanent pacemaker insertion, a client's telemetry monitor shows a pacer rhythm.
- B. Two hours after undergoing cardioversion, a client's telemetry monitor shows a normal sinus rhythm.
- C. A client started on carvedilol the previous day for heart failure has controlled atrial fibrillation.
- D. Four hours after admission, a client with syncope shows complete heart block on the telemetry monitor.
Correct answer: D
Rationale: The correct answer is D because complete heart block is a critical condition that requires immediate assessment and management by a registered nurse (RN). In complete heart block, there is a significant conduction disturbance that can lead to serious complications. The RN is better equipped to handle such complex and potentially life-threatening situations. Choices A, B, and C involve less critical conditions that can be managed by a practical nurse (PN) under the supervision of the RN. Therefore, assigning the client with complete heart block to the RN ensures prompt and appropriate intervention.
4. An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?
- A. Observe for signs of deep vein thrombosis.
- B. Administer a PRN dose of a muscle relaxant.
- C. Check the client’s most recent electrolyte values.
- D. Reduce the weight on the traction device.
Correct answer: B
Rationale: The correct answer is B: Administer a PRN dose of a muscle relaxant. Muscle spasms and pain might be relieved by muscle relaxants, which are appropriate before surgery. Choice A is incorrect because the client is experiencing muscle spasms, not signs of deep vein thrombosis. Choice C is not the most immediate action needed in this situation. Choice D is incorrect because reducing the weight on the traction device would not directly address the muscle spasms and pain reported by the client.
5. Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?
- A. Prevent the spread of infection to others
- B. Improve the function of the immune system
- C. Increase the ability to carry out activities of daily living
- D. Promote a feeling of general well-being
Correct answer: B
Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.
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