HESI LPN
HESI CAT Exam Quizlet
1. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase?
- A. RUQ abdominal pain
- B. Clay-colored stools
- C. Icteric sclera
- D. Pruritus
Correct answer: A
Rationale: During the preicteric phase of hepatitis A, the nurse should expect to find RUQ (right upper quadrant) abdominal pain. This pain is common in the early phase of hepatitis A and is associated with liver inflammation. Clay-colored stools (Choice B) are typically seen in the icteric phase when there is a lack of bile flow. Icteric sclera (Choice C) refers to yellowing of the eyes, which is a characteristic of the icteric phase. Pruritus (Choice D), which is itching of the skin, is also more commonly associated with the icteric phase when bile salts accumulate in the skin.
2. A 4-year-old child is admitted to the hospital with a diagnosis of epiglottitis. What is the priority nursing intervention?
- A. Administer antibiotics
- B. Provide humidified oxygen
- C. Keep the child NPO
- D. Position the child upright
Correct answer: C
Rationale: The priority nursing intervention for a 4-year-old child admitted to the hospital with epiglottitis is to keep the child NPO (nothing by mouth). Epiglottitis is a serious condition that can lead to airway obstruction. Keeping the child NPO helps prevent further compromise of the airway and reduces the risk of aspiration. Administering antibiotics may be necessary but ensuring the airway is not compromised takes precedence. Providing humidified oxygen is important for respiratory support, but not the priority over maintaining a patent airway. Positioning the child upright can help with breathing and comfort, but it does not directly address the immediate risk of airway compromise associated with epiglottitis.
3. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove the needle after discarding used syringes
- B. Wear gloves while disposing of the needle and syringe
- C. Wear a face mask during medication administration
- D. Wash hands before handling the needle and syringe
Correct answer: D
Rationale: The correct answer is D. Washing hands before handling the needle and syringe is a critical step in infection control and adherence to standard precautions. Clean hands help prevent the transfer of microorganisms and reduce the risk of infection. Choices A, B, and C do not directly relate to standard precautions. Removing the needle after discarding used syringes (Choice A) can increase the risk of needlestick injuries. Wearing gloves while disposing of the needle and syringe (Choice B) is important for personal protection but does not specifically address standard precautions. Wearing a face mask during medication administration (Choice C) is not directly related to handling syringes and needles, which are more pertinent to standard precautions.
4. When a client with hepatic encephalopathy is receiving lactulose, which parameter is essential to monitor for a response to the drug?
- A. Serum hepatic enzymes
- B. Fingerstick glucose
- C. Stool color and character
- D. Serum electrolytes and ammonia
Correct answer: D
Rationale: In hepatic encephalopathy, the goal of lactulose therapy is to reduce blood ammonia levels by promoting its excretion in the stool. Therefore, monitoring serum electrolytes and ammonia levels is crucial to assess the effectiveness of lactulose in lowering ammonia levels and improving the client's condition. Options A, B, and C are incorrect because serum hepatic enzymes, fingerstick glucose, and stool color/character are not directly related to monitoring the response to lactulose therapy in hepatic encephalopathy.
5. What is the function of the epiglottis during swallowing?
- A. Prevents food from entering the trachea
- B. Aids in food propulsion
- C. Enhances taste sensation
- D. Lubricates the esophagus
Correct answer: A
Rationale: The epiglottis is a flap of tissue that closes over the trachea during swallowing to prevent food and liquids from entering the airway. Choice A is correct because the primary function of the epiglottis is to act as a lid over the trachea, ensuring that food goes down the esophagus and not into the windpipe. Choices B, C, and D are incorrect as they do not describe the specific role of the epiglottis during swallowing.