HESI LPN
HESI CAT Exam
1. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?
- A. Ambulate with a walker for upper body support
- B. Perform abdominal curls to stretch the back muscles
- C. Position in semi-Fowler's with the knees flexed
- D. Encourage straight leg raises while lying supine
Correct answer: C
Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.
2. During the admission assessment, a female client requests that her husband be allowed to stay in the room. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take?
- A. Pay close attention and document the nonverbal messages
- B. Ask the client's husband to interpret the discrepancy
- C. Ignore the nonverbal behavior and focus on the client's verbal messages
- D. Integrate the verbal and nonverbal messages and interpret them as one
Correct answer: A
Rationale: Noting both verbal and nonverbal cues is crucial to fully understand the client's condition and any potential underlying issues. Verbal communication may not always align with nonverbal cues, which can provide valuable insights into the client's emotional state and concerns. By paying close attention to and documenting the nonverbal messages, the nurse can gather a more comprehensive understanding of the client's situation. Asking the client's husband to interpret the discrepancy may not be appropriate as it could lead to misinterpretation or breach of confidentiality. Ignoring the nonverbal behavior could result in missing essential cues affecting the overall assessment. Integrating both verbal and nonverbal messages helps in forming a holistic view of the client's needs and concerns, enabling better care delivery.
3. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Post-operatively, the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first?
- A. Notify the healthcare provider
- B. Administer the PRN dose of Albuterol
- C. Apply oxygen at 2 liters per nasal cannula
- D. Repeat the peak flow reading in 30 minutes
Correct answer: B
Rationale: In a client with moderate persistent asthma experiencing a drop in peak flow and chest tightness post-operatively, the first action the nurse should take is to administer the PRN dose of Albuterol. Albuterol is a short-acting bronchodilator that helps relieve bronchospasm and improve breathing. Notifying the healthcare provider (choice A) can be done after initiating immediate treatment with Albuterol. Applying oxygen (choice C) may be necessary but addressing the bronchospasm with Albuterol is the priority. Repeating the peak flow reading (choice D) can be considered after administering Albuterol to assess the response to treatment.
4. What will the treatment for a newly admitted child with cystic fibrosis center on?
- A. Chest physiotherapy
- B. Mucus-drying agents
- C. Prevention of diarrhea
- D. Insulin therapy
Correct answer: A
Rationale: The correct answer is A: Chest physiotherapy. Treatment for cystic fibrosis focuses on chest physiotherapy and aerosol medications to manage and clear thick pulmonary secretions. Chest physiotherapy helps loosen and clear mucus from the lungs, aiding in breathing and reducing the risk of infections. Mucus-drying agents (choice B) are not typically used in the treatment of cystic fibrosis as the goal is to help clear mucus, not dry it. Prevention of diarrhea (choice C) is not a primary focus in the treatment of cystic fibrosis. Insulin therapy (choice D) is not relevant to cystic fibrosis, which primarily affects the respiratory and digestive systems.
5. The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Abdomen
- D. Inner forearm
Correct answer: D
Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.