HESI LPN
HESI CAT Exam Quizlet
1. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?
- A. Sitting up and leaning forward
- B. Reclining with head elevated
- C. Sitting up with head tilted back
- D. Lying flat on the back
Correct answer: A
Rationale: The correct position for a child with a nosebleed (epistaxis) is sitting up and leaning forward. This position helps prevent blood from flowing into the throat and causing choking. Choice B, reclining with the head elevated, and choice D, lying flat on the back, are incorrect as they can cause blood to flow backward into the throat. Choice C, sitting up with the head tilted back, is also incorrect as it can lead to blood flowing down the back of the throat and potentially into the airway.
2. Which individual has the highest risk for developing skin cancer?
- A. A 16-year-old dark-skinned female who tans in tanning beds once a week.
- B. A 65-year-old fair-skinned male who is a construction worker
- C. A 25-year-old dark-skinned male whose mother had skin cancer.
- D. A 70-year-old fair-skinned female who works as a secretary.
Correct answer: B
Rationale: The correct answer is B, a 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals are at higher risk of developing skin cancer due to prolonged sun exposure. Construction workers are often exposed to the sun for long periods, further increasing the risk. Choices A, C, and D are less likely to develop skin cancer compared to choice B due to factors such as age, frequency of tanning bed use, and occupation.
3. When providing postmortem care to a client diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) who has passed away, what type of precautions is appropriate to use?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct answer: C
Rationale: Contact precautions are the appropriate type to use when performing postmortem care for a client with MRSA. MRSA is primarily spread through direct contact, so using contact precautions helps prevent the transmission of the infection. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air like tuberculosis or measles. Droplet precautions are used for diseases transmitted through respiratory droplets like influenza. Compromised host precautions are not a standard precaution type and are not specific to managing MRSA infection.
4. A client has a terminal diagnosis and their health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
- A. Offering to discuss advance directives and provide brochures respects the client's request and provides information.
- B. Informing the client that advance directives are not necessary at this time is incorrect as they play a crucial role in end-of-life care.
- C. Scheduling a meeting with the family to discuss advance directives is not the most appropriate response as the client directly requested information.
- D. Directing the client to ask their provider about advance directives does not directly address the client's request for information.
Correct answer: A
Rationale: When a client with a terminal illness asks about advance directives, it is essential to provide the information they seek. Choice A is the correct response as it acknowledges the client's request and offers to discuss advance directives while providing additional resources in the form of brochures. This approach empowers the client to make informed decisions about their end-of-life care. Choices B, C, and D are incorrect because they do not directly address the client's request or provide the information the client is seeking. Choice B dismisses the importance of advance directives, which are crucial in end-of-life care planning. Choice C involves the family unnecessarily when the client directly requested information. Choice D deflects the responsibility back to the client to seek information from their provider instead of addressing their immediate request.
5. A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) is made and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?
- A. Place the infant in a warm, dry environment.
- B. Allow parents and siblings to visit.
- C. Maintain standard and contact precautions.
- D. Administer prescribed antibiotics immediately.
Correct answer: C
Rationale: The correct answer is to maintain standard and contact precautions. RSV is highly contagious, primarily spreading through respiratory secretions. Therefore, it is crucial to implement infection control measures to prevent the spread of the virus within the healthcare setting. Option A is incorrect as warmth and dryness are not the primary concern in RSV management. While family support is important, allowing visits may increase the risk of spreading the infection, making option B less appropriate. Option D is incorrect because RSV is a viral infection, and antibiotics are not effective against viruses.