HESI LPN
HESI CAT
1. A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?
- A. From the peak of one contraction to the peak of the next contraction
- B. From the beginning of one contraction to the end of that contraction
- C. From the beginning of one contraction to the beginning of the next contraction
- D. From the end of one contraction to the beginning of the next contraction
Correct answer: C
Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.
2. A 16-year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?
- A. Ask the teenager to wait until a parent or legal guardian can be contacted
- B. Withhold treatment until telephone consent can be obtained from the partner
- C. Refer the teenager to a community pediatric hospital emergency department
- D. Proceed with the triage process in the same manner as any adult client
Correct answer: D
Rationale: The correct answer is to proceed with the triage process in the same manner as any adult client. In this scenario, since the teenager is legally married, they have the legal authority to consent to their own treatment. Choice A is incorrect because the teenager, being legally married, can provide their own consent. Choice B is incorrect as it unnecessarily delays treatment by waiting for telephone consent from the partner, which is not required in this case. Choice C is incorrect as the teenager can receive appropriate care in the current emergency department setting without the need for referral.
3. Which nursing action prevents injury to a client's eye during the administration of eye drops?
- A. Holding the tip of the container above the conjunctival sac
- B. Rinsing the eye with saline before administration
- C. Placing the client in a supine position
- D. Pressing gently on the lower eyelid to open the eye
Correct answer: A
Rationale: The correct nursing action to prevent injury to a client's eye during the administration of eye drops is to hold the tip of the container above the conjunctival sac. This technique helps to prevent direct contact between the container and the eye, reducing the risk of injury. Rinsing the eye with saline before administration (Choice B) is not a standard practice and may not necessarily prevent injury. Placing the client in a supine position (Choice C) is not directly related to preventing eye injury during eye drop administration. Pressing gently on the lower eyelid to open the eye (Choice D) is not recommended as it can potentially cause injury or discomfort to the client.
4. How should the nurse manage a child with acute lymphoblastic leukemia (ALL) who is receiving chemotherapy?
- A. Avoid all physical activity
- B. Ensure strict infection control measures
- C. Increase daily caloric intake
- D. Limit fluid intake
Correct answer: B
Rationale: The correct answer is B: Ensure strict infection control measures. Children with acute lymphoblastic leukemia (ALL) who are undergoing chemotherapy have compromised immune systems, making them highly susceptible to infections. Implementing strict infection control measures, such as hand hygiene, limiting exposure to sick individuals, and maintaining a clean environment, is essential to prevent infections. Choice A is incorrect because avoiding all physical activity may not be necessary as long as the child's activity level is appropriate. Choice C is incorrect because increasing daily caloric intake is important to support the child's nutritional needs during treatment. Choice D is incorrect because limiting fluid intake is not typically recommended unless specifically advised by the healthcare provider.
5. What is the primary focus of primary healthcare?
- A. Emergency care
- B. Preventive care
- C. Specialized treatment
- D. Hospital-based services
Correct answer: B
Rationale: The correct answer is B: Preventive care. Primary healthcare emphasizes preventive care, which includes promoting overall health, preventing diseases, and providing early intervention to avoid the progression of illnesses. Emergency care (choice A) is focused on immediate medical attention for urgent health situations but is not the primary focus of primary healthcare. Specialized treatment (choice C) refers to care provided by specialists for specific health conditions, which is not the main focus of primary healthcare. Hospital-based services (choice D) involve inpatient care provided in a hospital setting, which is not the primary focus of primary healthcare that aims to provide comprehensive and accessible care at the community level.