HESI LPN
HESI CAT Exam 2022
1. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?
- A. The client has asymmetrical chest wall expansion
- B. The client complains of pain at the insertion site
- C. The client's chest x-ray indicates decreased pleural effusion
- D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26
Correct answer: A
Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.
2. What should be taught to the child and parents about using a peak flow meter for a child diagnosed with asthma?
- A. Use the device before taking medication
- B. Use the device during asthma attacks
- C. Record the best of three attempts
- D. Use the device after eating
Correct answer: C
Rationale: The correct answer is to 'Record the best of three attempts.' This method provides an accurate measure of peak expiratory flow using a peak flow meter. By taking the best of three attempts, the child and parents can obtain a more reliable assessment of the child's lung function. Choices A, B, and D are incorrect because using the device before taking medication, during asthma attacks, or after eating does not ensure an accurate measurement of peak flow, which is essential for managing asthma effectively. Monitoring peak flow regularly and accurately can help in adjusting asthma treatment plans and assessing response to medications.
3. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?
- A. Perform hand hygiene
- B. Identify the client using two identifiers
- C. Prepare the sterile field
- D. Don sterile gloves
Correct answer: A
Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.
4. When caring for a child with Reye's Syndrome, which action should the nurse give the highest priority?
- A. Monitor intake and output
- B. Provide good skin care
- C. Assess level of consciousness
- D. Assist with range of motion
Correct answer: C
Rationale: Assessing the level of consciousness is crucial when caring for a child with Reye's Syndrome. Changes in neurological status can indicate deterioration of the condition, necessitating immediate medical attention. Monitoring intake and output is important but not the highest priority compared to assessing the child's level of consciousness. Providing good skin care and assisting with range of motion are also important aspects of care but take a lower priority than assessing the child's neurological status in this critical condition.
5. A client reports pain after medication administration. What is the next best step for the nurse?
- A. Reassess the client’s pain
- B. Increase the pain medication dose
- C. Apply a cold compress
- D. Contact the healthcare provider
Correct answer: A
Rationale: The correct answer is to reassess the client’s pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.