HESI LPN
HESI CAT
1. A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. Which breakfast items should the nurse encourage the client to eat? (Select all that apply)
- A. Sausage patties and eggs
- B. Whole wheat toast and jam
- C. Bagels and cream cheese
- D. Blackberries and oatmeal
Correct answer: B
Rationale: The correct choices are whole wheat toast and jam (B) and blackberries and oatmeal (D). Whole wheat toast and blackberries are high in fiber, which can help lower cholesterol levels. Sausage patties and eggs (A) are high in saturated fats that can raise cholesterol levels. Bagels and cream cheese (C) are not as beneficial for cholesterol control compared to high-fiber options like whole wheat toast and blackberries.
2. A client with epilepsy is prescribed lamotrigine. The nurse should monitor for which potential side effect?
- A. Drowsiness
- B. Nausea and vomiting
- C. Skin rash
- D. Dizziness
Correct answer: C
Rationale: When a client is prescribed lamotrigine, the nurse should closely monitor for the potential side effect of skin rash. Lamotrigine is known to cause skin rashes, which can be mild or severe, indicating a serious adverse reaction like Stevens-Johnson syndrome. Monitoring for skin rash is crucial to detect any signs of severe allergic reactions early and prevent further complications. Choices A, B, and D are incorrect as drowsiness, nausea and vomiting, and dizziness are not typically associated with lamotrigine use. While dizziness can be a side effect of some antiepileptic medications, it is not a common side effect of lamotrigine.
3. The healthcare provider reviews the laboratory results of a client whose serum pH is 7.38. What does this value imply about the client's homeostasis?
- A. Alkalosis
- B. Acidosis
- C. Normal serum pH
- D. Incompatible with life
Correct answer: C
Rationale: A pH of 7.38 falls within the normal range (7.35-7.45), indicating that the client’s acid-base balance is adequately maintained. Choices A and B are incorrect as alkalosis and acidosis refer to abnormal pH levels. Choice D is incorrect as a pH of 7.38 within the normal range is compatible with life.
4. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?
- A. Alert the American Nurses Association.
- B. Fill out an incident report.
- C. Report the observations to the nurse manager on the unit.
- D. Leave the nurse alone to sleep.
Correct answer: C
Rationale: Reporting the observations to the nurse manager is the appropriate action to ensure the safety of the clients and address potential impairment. The nurse manager can take necessary steps to assess the situation and intervene if needed. Alerting the American Nurses Association (Choice A) is not necessary at this stage as the immediate concern is the safety of clients in the unit. Filling out an incident report (Choice B) may be required later, but the priority is to address the issue promptly by involving the immediate supervisor. Leaving the nurse alone to sleep (Choice D) is not a safe option as it does not address the underlying problem of potential impairment and safety concerns; it is essential to address the issue promptly to ensure patient safety.
5. A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?
- A. Dizziness while standing
- B. Sinus tachycardia
- C. Lower back pain
- D. Absent patellar reflexes
Correct answer: D
Rationale: The correct answer is D: Absent patellar reflexes. Absent patellar reflexes can indicate magnesium toxicity, a serious condition that requires immediate intervention to prevent respiratory depression or cardiac arrest. Dizziness while standing (choice A) is common in pregnancy but does not specifically indicate magnesium toxicity. Sinus tachycardia (choice B) can be a normal response to magnesium sulfate but does not indicate toxicity. Lower back pain (choice C) is common in pregnancy and not specifically associated with magnesium toxicity.