HESI LPN
HESI CAT
1. A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first?
- A. Cleanse the site around the catheter
- B. Use a 20 ml syringe to deflate balloon
- C. Clamp catheter until the client voids naturally
- D. Empty urine from the urinary drainage bag
Correct answer: B
Rationale: The correct answer is to use a 20 ml syringe to deflate the balloon first when removing a suprapubic catheter. This step is essential to ensure the safe removal of the catheter without causing any harm or discomfort to the client. Deflating the balloon allows for the catheter to be easily removed. Option A, cleansing the site around the catheter, is not the initial step in this process and can be done after catheter removal. Option C, clamping the catheter until the client voids naturally, is incorrect as it can lead to complications like urinary retention. Option D, emptying urine from the urinary drainage bag, is not the first step in removing the suprapubic catheter and does not address the need to deflate the balloon for safe removal.
2. A pre-term baby develops nasal flaring, cyanosis, and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?
- A. Cardiopulmonary resuscitation
- B. Insertion of a chest tube
- C. Oxygen therapy
- D. Assisted ventilation
Correct answer: B
Rationale: The correct answer is B: Insertion of a chest tube. In a case of spontaneous pneumothorax, the primary intervention is to insert a chest tube. This procedure allows the trapped air to escape from the pleural space, relieving pressure and enabling the lung to re-expand. Choices A, C, and D are not the initial interventions for spontaneous pneumothorax. Cardiopulmonary resuscitation is indicated for cardiac arrest, oxygen therapy may provide supportive care but does not address the underlying issue of trapped air in the pleural space, and assisted ventilation may be needed later but is not the first-line treatment for a pneumothorax.
3. What is the most common initial symptom of juvenile idiopathic arthritis?
- A. Joint swelling and pain
- B. Skin rash
- C. Gastrointestinal bleeding
- D. Neurological deficits
Correct answer: A
Rationale: The correct answer is A: Joint swelling and pain. These are the most common initial symptoms of juvenile idiopathic arthritis, typically affecting multiple joints. Skin rash (choice B), gastrointestinal bleeding (choice C), and neurological deficits (choice D) are not typical initial symptoms of juvenile idiopathic arthritis. Skin rash may be seen in other conditions like dermatitis or systemic lupus erythematosus, gastrointestinal bleeding may be associated with conditions like inflammatory bowel disease, and neurological deficits could be indicative of conditions like multiple sclerosis.
4. In order to be effective as an occupational health nurse, you should be equipped with knowledge and skills in which of the following:
- A. public health science
- B. research process
- C. interviewing and counseling
- D. oral and written communication
Correct answer: D
Rationale: To be effective as an occupational health nurse, having knowledge and skills in public health science, the research process, interviewing and counseling, and oral and written communication are all important. However, communication skills, both oral and written, are crucial for conveying information, educating employees, documenting findings, and collaborating with other healthcare professionals. While public health science, research process, interviewing, and counseling are essential, oral and written communication is fundamental for effective communication and coordination in the workplace, making it the most critical skill for an occupational health nurse.
5. When a mother confides in the nurse that she is contemplating divorce, which suggestion by the nurse would help minimize the effects on the child?
- A. Tell the child together using appropriate terms.
- B. Reassure the child that no one loves him more than his parents.
- C. Engage in special activities with the child to compensate for the divorce.
- D. Discuss your feelings with the child.
Correct answer: A
Rationale: The correct answer is A. It is essential for both parents to inform the child about the divorce together, using age-appropriate language. This approach can help minimize the negative impact on the child by providing a sense of unity and understanding. Choice B is incorrect because offering false reassurance about love may not address the child's concerns effectively, as the situation is complex. Choice C is not suitable as engaging in special activities cannot substitute for the emotional stability that the child may lose due to the divorce. Choice D is incorrect because sharing the parent's feelings may burden the child with adult emotions, which could be overwhelming and confusing for their developmental stage.