HESI LPN
HESI CAT Exam Test Bank
1. 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.
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. 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.
4. A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?
- A. Follow the prompts of the AED
- B. Apply the AED pads to the client’s chest
- C. Wipe the client’s chest dry
- D. Move the client from the bathroom
Correct answer: B
Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.
5. In conducting the admission assessment for a client experiencing complications of long-term Parkinson’s disease, which question by the nurse provides the best information about disease progression?
- A. Have you experienced any stiffness in your neck or shoulder?
- B. Do you notice any jerky-type movements of your arms?
- C. Have you ever been frozen to a spot and unable to move?
- D. Do you have any problems with your hands shaking?
Correct answer: C
Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson’s disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson’s disease but do not specifically address the aspect of disease progression related to freezing episodes.
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