HESI LPN
HESI CAT Exam Test Bank
1. A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in the discharge teaching?
- A. Engage in physical exercise before eating to help decrease cholesterol levels.
- B. Avoid walking briskly in cold weather to prevent a decrease in cardiac output.
- C. Keep nitroglycerin in a light-colored plastic bottle and readily available.
- D. Avoid all isometric exercises, but walk regularly.
Correct answer: C
Rationale: The correct answer is to keep nitroglycerin in a light-colored container and readily available. Nitroglycerin should be protected from light to maintain its effectiveness. Option A is incorrect because physical exercise immediately before eating can trigger angina. Option B is incorrect as cold weather can exacerbate angina symptoms. Option D is incorrect as isometric exercises can increase the workload on the heart, which is not recommended for individuals with angina.
2. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer’s at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 900 mL in the last 24 hours
- B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
- C. Increased blood urea nitrogen (BUN)
- D. 24-hour intake at the current infusion rate
Correct answer: B
Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.
3. The client enters the room of a client with Parkinson’s disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?
- A. Demonstrate how to help the client move more efficiently
- B. Offer a PRN analgesic to reduce painful movement
- C. Affirm that the client should arise slowly from the chair
- D. Tell the UAP to assist the client in moving more quickly
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.
4. To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?
- A. Verify the feeding tube position with a daily chest x-ray
- B. Maintain head of bed elevated while enteral feeding is infusing
- C. Check feeding tube placement with air bolus prior to use
- D. Aspirate stomach contents every 4 hours to assess residuals
Correct answer: B
Rationale: The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.
5. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give the child sugar water only
- B. Maintain intravenous fluid therapy per prescription
- C. Provide Pedialyte feedings via the nasogastric tube
- D. Offer the infant Pedialyte feedings every 2 hours
Correct answer: B
Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.
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