HESI LPN
HESI CAT Exam Test Bank
1. The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?
- A. Consult the healthcare provider for recommendations on pain management
- B. Schedule the client for physical therapy to manage pain
- C. Recommend the client attend a support group for cancer patients
- D. Suggest alternative therapies like acupuncture or massage
Correct answer: A
Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.
2. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis, 'altered nutrition, less than body requirements related to anorexia, nausea, vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Allow the child to eat foods desired and tolerated
- B. Restrict foods brought from fast food restaurants
- C. Recommend eating the same foods as siblings eat at home
- D. Encourage a variety of large portions of food at every meal
Correct answer: A
Rationale: Allowing the child to choose foods can help improve intake and reduce nausea. Choice A is the correct intervention as it empowers the child to select foods they desire and can tolerate, which is crucial in ensuring adequate nutrition intake. Choice B is incorrect because restricting certain foods can further limit the child's options and may not address the underlying issues. Choice C is incorrect as it doesn't consider the specific needs and preferences of the child with altered nutrition. Choice D is incorrect as encouraging large portions of food at every meal may be overwhelming for a child experiencing anorexia, nausea, and vomiting.
3. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)
- A. Protect the medication from light exposure
- B. Monitor for changes in level of consciousness
- C. Observe for onset of generalized bruising or bleeding
- D. Perform ongoing assessment of respiratory status
Correct answer: D
Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.
4. 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.
5. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?
- A. Administer the prescribed amiodarone (Cordarone) immediately
- B. Institute a daily fluid restriction while the client is in the hospital
- C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
- D. Place the client in the Trendelenburg position to facilitate perfusion
Correct answer: A
Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.
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