HESI LPN
HESI CAT Exam
1. A client is admitted with severe dehydration. What is the most important assessment finding for the nurse to monitor?
- A. Changes in mental status
- B. Urine output and color
- C. Blood pressure and heart rate
- D. Skin turgor
Correct answer: A
Rationale: Changes in mental status are crucial to monitor in a client with severe dehydration. Altered mental status, such as confusion or lethargy, can indicate severe dehydration and potential complications like electrolyte imbalances affecting the brain. Monitoring urine output and color (choice B) is essential but may not provide immediate signs of severe dehydration. While monitoring blood pressure and heart rate (choice C) is important, changes in mental status take precedence as they can indicate more critical conditions. Skin turgor (choice D) is a valuable assessment for dehydration, but changes in mental status take priority due to their direct correlation with severe dehydration.
2. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?
- A. Emphasize the importance of active foot flexion
- B. Check the surgical dressing
- C. Complete an incident report
- D. Explain the use of an incentive spirometer every 2 hours
Correct answer: A
Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.
3. An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?
- A. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors.
- B. Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities.
- C. Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse.
- D. Encourage the client to avoid becoming involved in the neighbor’s problems for one’s protection.
Correct answer: C
Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor’s safety and well-being. Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse. Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities. Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.
4. A child with a diagnosis of bronchiolitis is admitted to the hospital. What is the most important nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct answer: B
Rationale: The most important nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention helps to maintain airway patency and improve breathing by assisting with mucus clearance and ventilation. Administering bronchodilators (Choice A) may be considered in some cases, but it is not the most crucial intervention for bronchiolitis. Monitoring oxygen saturation (Choice C) is important but is not as directly impactful as providing respiratory therapy. Encouraging fluid intake (Choice D) is important for hydration but does not directly address the respiratory distress associated with bronchiolitis.
5. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?
- A. Consult the medication reference book available on the unit.
- B. Administer the medication as ordered.
- C. Ask a colleague for information about the medication.
- D. Contact the provider to clarify the medication.
Correct answer: A
Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.