HESI LPN
HESI CAT Exam
1. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?
- A. Does she know the person who raped her?
- B. Has she taken a bath since the rape occurred?
- C. Is the place where she lives a safe place?
- D. Did she report the rape to the police department?
Correct answer: A
Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.
2. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?
- A. 13 to 18 years of age.
- B. 11 to 12 years of age.
- C. 18 to 24 months of age.
- D. 4 to 6 years of age.
Correct answer: D
Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.
3. A client has been prescribed losartan. Which change in data indicates to the practical nurse (PN) that the desired effect of this medication has been achieved?
- A. Dependent edema reduced from +3 to +1.
- B. Serum HDL increased from 35 to 55 mg/dL.
- C. Pulse rate reduced from 150 to 90 beats/min.
- D. Blood pressure reduced from 160/90 to 130/80 mm Hg.
Correct answer: D
Rationale: The correct answer is D. Losartan is prescribed for the treatment of hypertension. The desired effect of losartan is to reduce blood pressure. Therefore, a reduction in blood pressure from 160/90 to 130/80 mm Hg indicates that the desired effect of the medication has been achieved. Choices A, B, and C are not specific effects of losartan and do not directly relate to the expected outcomes of this medication. Dependent edema, serum HDL levels, and pulse rate are not typically influenced by losartan, making choices A, B, and C incorrect.
4. The patient is admitted to a skilled care unit for rehabilitation after the surgical procedure of fixation of a fractured left hip. The patient's nursing diagnosis is Impaired physical mobility related to musculoskeletal impairment from surgery and pain with movement. The patient is able to use a walker but needs assistance ambulating and transferring from the bed to the chair. Which nursing intervention is most appropriate for this patient?
- A. Obtain assistance and physically transfer the patient to the chair.
- B. Assist with ambulation and measure how far the patient walks.
- C. Give pain medication after ambulation so the patient will have a clear mind.
- D. Bring the patient to the cafeteria for group instruction on ambulation.
Correct answer: B
Rationale: The most appropriate nursing intervention for this patient is to assist with ambulation and measure how far the patient walks. This intervention helps quantify the patient's progress in mobility and rehabilitation. Choice A is incorrect because physically transferring the patient does not focus on promoting independence or assessing progress. Choice C is inappropriate as pain medication should be given based on scheduled times or as needed, not specifically after ambulation. Choice D is not suitable as group instruction on ambulation is not as individualized or focused on the patient's current needs and abilities.
5. An infant who had cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administering the prescribed antibiotic?
- A. Give the antibiotic between feedings.
- B. Ensure that the antibiotic is administered as prescribed.
- C. Shake the bottle thoroughly before giving the antibiotic.
- D. Keep the antibiotic in the refrigerator after the bottle has been opened.
Correct answer: B
Rationale: The correct answer is B: 'Ensure that the antibiotic is administered as prescribed.' It is crucial for the parents to follow the prescribed antibiotic regimen to prevent infections and promote proper healing following cardiac surgery. Option A is incorrect because the timing of antibiotic administration may vary depending on the specific medication and instructions. Option C is not necessary and could potentially affect the antibiotic's effectiveness. Option D is not relevant to the administration of the antibiotic and does not ensure proper usage.