HESI LPN
HESI CAT Exam
1. A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Observe for bleeding side effects related to heparin therapy.
- B. Assess blood pressure and heart rate at least every 4 hours.
- C. Measure calf girth to evaluate edema in the affected leg.
- D. Encourage mobilization to prevent pulmonary embolism.
Correct answer: A
Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.
2. When reconstituted, how many milligrams are in each milliliter of solution?
- A. 300 mg/mL
- B. 350 mg/mL
- C. 450 mg/mL
- D. 400 mg/mL
Correct answer: D
Rationale: After reconstitution, the concentration of the cefazolin solution is 400 mg/mL. This calculation is derived by dividing the total milligrams in the vial (1000 mg) by the total volume after reconstitution (2.5 mL). Therefore, each milliliter of the solution contains 400 mg of cefazolin. Choices A, B, and C are incorrect as they do not match the correct calculation based on the information provided.
3. A client with herpes zoster asks the nurse about using complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Feverfew
- D. Acupuncture
Correct answer: D
Rationale: Acupuncture is contraindicated for clients with herpes zoster due to the risk of introducing an open portal on the skin, which can increase the risk of infection. This therapy involves inserting needles into specific points on the body, potentially causing skin trauma and providing a route for the virus to spread. Biofeedback, aloe, and feverfew are not contraindicated for clients with herpes zoster and can be considered for pain management in this condition. Biofeedback involves using electronic devices to help individuals learn to control physiological processes, aloe is a plant known for its skin-soothing properties, and feverfew is an herb that has been used for pain relief.
4. The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?
- A. Ensure continuous bubbling in the water seal chamber
- B. Measure the amount of drainage every shift
- C. Keep the drainage system at the level of the chest
- D. Assess for subcutaneous emphysema around the insertion site
Correct answer: D
Rationale: The most important assessment related to a chest tube after thoracic surgery is to assess for subcutaneous emphysema around the insertion site. Subcutaneous emphysema can indicate air leakage from the pleural space, which can lead to serious complications such as a pneumothorax. Ensuring continuous bubbling in the water seal chamber is not the most critical assessment as it is a normal finding in a chest drainage system. While measuring the amount of drainage is important to monitor the client's condition, it is not as crucial as assessing for subcutaneous emphysema. Keeping the drainage system at the level of the chest helps maintain proper function but is not the most critical assessment in this scenario.
5. What is the primary purpose of a placebo in an experiment?
- A. To reduce the cost of the experiment.
- B. To make the experiment double-blind.
- C. To increase the number of participants.
- D. To serve as a control for comparison with the treatment group.
Correct answer: D
Rationale: The correct answer is D. A placebo serves as a control for comparison with the treatment group, helping to eliminate bias and ensure the results are due to the treatment itself. Placebos are crucial in research to distinguish the actual effect of the treatment from psychological or subjective factors. Choice A is incorrect because the purpose of a placebo is not related to reducing the cost of the experiment. Choice B is incorrect because while placebos are used in double-blind studies, their primary purpose is not to make the experiment double-blind. Choice C is incorrect because the purpose of a placebo is not to increase the number of participants but rather to serve as a comparison group for the treatment being tested.