HESI LPN
CAT Exam Practice
1. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbecue that afternoon. What question is most important for the triage nurse to ask this client?
- A. Have you recently traveled outside the United States?
- B. How high was your temperature when you returned home?
- C. Have you taken any medication to treat these symptoms?
- D. Is anyone else sick who was also at the picnic?
Correct answer: D
Rationale: The most important question for the triage nurse to ask the client in this scenario is whether anyone else who attended the picnic is also sick. This is crucial to identify a potential outbreak or common source of infection. Asking about recent travel may be important for infectious diseases but is not as relevant as identifying a common source among individuals who shared the same food. Inquiring about the client's temperature is important but does not provide immediate insight into the cause of symptoms. Asking about medication taken is relevant but not as critical as determining if others are affected, which could indicate a foodborne illness.
2. 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.
3. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?
- A. Apply heat to the residual limb.
- B. Administer prescribed analgesics.
- C. Elevate the residual limb.
- D. Perform range-of-motion exercises.
Correct answer: B
Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.
4. What is the best thing to say to a patient scheduled for cataract surgery who is concerned that the physician works on the correct eye?
- A. You are wearing an ID bracelet that will let the medical team know which eye to work on.
- B. When you are taken to the surgery area, the medical staff will confirm which eye needs the surgery.
- C. The surgeon will mark the correct eye before the cataract surgery based on your medical records.
- D. You will wear an ID bracelet, and the nurse will verify the eye scheduled for surgery by comparing it with your records and marking it with a permanent marker.
Correct answer: D
Rationale: The best response reassures the patient by explaining the process of verifying and marking the correct eye, a safety measure to prevent wrong-site surgery, directly addressing the patient’s concern. Choice A is close but implies the ID bracelet alone determines the correct eye, missing the verification process. Choice B talks about confirmation but lacks details about marking the correct eye. Choice C mentions the surgeon's record but does not specify the direct verification and marking process, unlike Choice D.
5. The nurse is caring for a patient who is immobile and needs to be turned every 2 hours. The patient has poor lower extremity circulation, and the nurse is concerned about irritation of the patient's toes. Which device will the nurse use?
- A. Hand rolls
- B. A foot cradle
- C. A trapeze bar
- D. A trochanter roll
Correct answer: B
Rationale: A foot cradle is the correct choice for this situation. A foot cradle is used to reduce pressure on the tips of a patient's toes in individuals with poor lower extremity circulation. Hand rolls are not designed to address toe irritation specifically. A trapeze bar is used to assist patients with repositioning in bed, and a trochanter roll is used to support the hips and prevent external rotation of the legs, neither of which directly address toe irritation in this scenario.