HESI LPN
HESI CAT Exam 2022
1. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?
- A. Wear a dosimeter film badge when in the client’s room
- B. Spend 30 minutes at the bedside when providing direct care
- C. Change the linens every day after assisting with a bed bath
- D. Use gloves to remove the applicator if it is dislodged in the bed
Correct answer: A
Rationale: The correct action for the nurse to implement when caring for a client with a radioactive Cesium-loaded vaginal applicator during brachytherapy is to wear a dosimeter film badge when in the client’s room. Wearing a dosimeter badge is essential to monitor radiation exposure and ensure the safety of healthcare providers. Choice B is incorrect as the duration is not specified and unnecessary. Choice C is incorrect as changing linens daily does not directly relate to radiation safety. Choice D is incorrect as using gloves to remove the applicator if dislodged is important but not the primary action to monitor radiation exposure.
2. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
3. A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). The client asks, 'How long will it take for this medication to work?' What is the best response by the nurse?
- A. It may take 2 to 4 weeks before you start feeling better.
- B. You should start feeling better within a few days.
- C. The medication works immediately to improve your mood.
- D. It may take up to 8 weeks for the medication to take full effect.
Correct answer: D
Rationale: Explaining that it may take up to 8 weeks for the medication to take full effect provides the client with a realistic expectation. SSRI medications typically require time to build up in the body and exert their therapeutic effects. Choice A is incorrect as it underestimates the time frame required for the medication to work. Choice B is incorrect as SSRIs do not produce immediate effects. Choice C is incorrect as it falsely states that the medication works immediately, which is not true for SSRIs.
4. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, 'I'm finally cured.' The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:
- A. Suggesting a reduction of medication
- B. Allowing increased 'in-room' activities
- C. Increasing the level of suicide precautions
- D. Allowing the client off-unit privileges as needed
Correct answer: C
Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.
5. Which best describes a full-thickness (third-degree) burn?
- A. Erythema and pain
- B. Skin showing erythema followed by blister formation
- C. Destruction of all layers of skin evident with extension into subcutaneous tissue
- D. Destruction injury involving underlying structures such as muscle, fascia, and bone
Correct answer: C
Rationale: A full-thickness (third-degree) burn involves the destruction of all layers of skin, including the epidermis, dermis, and extending into the subcutaneous tissue. This type of burn results in significant tissue damage and can appear pale, charred, or leathery. Choice A is incorrect as erythema and pain are more characteristic of superficial burns. Choice B describes a partial-thickness burn where the skin shows erythema followed by blister formation, involving the epidermis and part of the dermis. Choice D is incorrect as it describes a deeper type of injury involving structures beyond the skin layers, such as muscle, fascia, and bone, which is not specific to a full-thickness burn.