HESI LPN
CAT Exam Practice
1. In what order should the nurse assess a lethargic one-hour-old infant brought to the nursery?
- A. Heel stick
- B. Respirations
- C. Heart rate
- D. Temperature
Correct answer: D
Rationale: When assessing a lethargic one-hour-old infant, the nurse should prioritize assessing the most critical parameters first. Temperature and heart rate are vital signs that provide immediate information about the infant's well-being. Therefore, the correct order of assessment should be temperature, heart rate, respirations, and then a heel stick. Temperature is crucial to determine if the infant is hypothermic or hyperthermic, while heart rate gives insight into the circulatory system's function. Respirations follow to evaluate the infant's breathing pattern. Lastly, the heel stick is important for certain screenings but is not as urgent as evaluating temperature and heart rate in a lethargic infant.
2. What should be a priority for a 4-year-old child with nephrosis?
- A. Impaired body image
- B. Skin impairment
- C. Nutritional deficit
- D. Injury
Correct answer: B
Rationale: The correct answer is B: Skin impairment. Skin care is a priority in nephrosis due to edema and increased risk of skin breakdown, requiring careful monitoring and management. While impaired body image (Choice A) can be a concern, it is not typically a priority in a 4-year-old with nephrosis. Nutritional deficit (Choice C) is important but addressing skin impairment takes precedence due to the immediate risk of complications related to skin breakdown. Injury (Choice D) is a general concern for children but is not the priority in a child with nephrosis.
3. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?
- A. allow the head to deliver and check for the location of the cord
- B. advise your partner to stop the ambulance and assist with the delivery
- C. tell the mother to take short, quick breaths until you arrive at the hospital
- D. prepare the mother for an emergency delivery and open the obstetrics kit
Correct answer: B
Rationale: The correct action in this scenario is to advise your partner to stop the ambulance and assist with the delivery. When the mother feels the urge to push and you see the baby's head bulging from the vagina, it indicates an imminent delivery. Stopping the ambulance allows for a safer environment for the delivery of the baby and ensures that immediate assistance can be provided to both the mother and the newborn. Allowing the head to deliver before checking for the cord (Choice A) may delay necessary interventions in case of complications. Instructing the mother to take short, quick breaths (Choice C) is not appropriate when the baby's head is already visible. Preparing for an emergency delivery and opening the obstetrics kit (Choice D) is important but should come after stopping the ambulance and assisting with the imminent birth.
4. What is a common symptom of an upper respiratory infection in children?
- A. Constipation
- B. Excessive vomiting
- C. Nasal congestion
- D. Abdominal pain
Correct answer: C
Rationale: Nasal congestion is a common symptom of an upper respiratory infection in children. It is typically accompanied by cough and sore throat. Constipation (choice A) and excessive vomiting (choice B) are not typical symptoms of upper respiratory infections. Abdominal pain (choice D) is more commonly associated with gastrointestinal issues rather than upper respiratory infections.
5. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction?
- A. A client who has a new diagnosis of adrenal insufficiency
- B. A client who has heart failure
- C. A client who is receiving treatment for diabetic ketoacidosis
- D. A client who has abdominal ascites
Correct answer: B
Rationale: The correct answer is B. Fluid restriction is commonly prescribed for clients with heart failure to prevent fluid overload and exacerbation of heart failure symptoms. Heart failure often leads to fluid retention, and restricting fluid intake can help manage this condition. Adrenal insufficiency, diabetic ketoacidosis, and abdominal ascites do not typically require fluid restriction as a primary intervention. Adrenal insufficiency may require hormone replacement therapy, diabetic ketoacidosis requires fluid and electrolyte replacement, and abdominal ascites may require diuretics or paracentesis to remove excess fluid.