HESI LPN
HESI CAT Exam 2022
1. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply)
- A. Take out dentures and place them in a labeled cup
- B. Apply a body shroud
- C. Place a small pillow under the head
- D. Gently close the eyes
Correct answer: A
Rationale: The correct interventions for the nurse to prepare the body before the family enters the room include taking out dentures and placing them in a labeled cup. This is essential to ensure the dignity of the deceased and maintain their appearance. Applying a body shroud is not typically done before the family views the body, as it may be more appropriate during preparation for transportation to the funeral home. Placing a small pillow under the head and gently closing the eyes are actions that can be comforting but are not essential preparations for the family viewing.
2. Which cardiac defects are associated with tetralogy of Fallot?
- A. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis
- B. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle
- C. Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
- D. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy, and an atrial septal defect
Correct answer: C
Rationale: Tetralogy of Fallot is characterized by a combination of four specific cardiac defects: right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of tetralogy of Fallot. Choice B describes transposition of the great arteries rather than tetralogy of Fallot. Choice D includes an atrial septal defect, which is not part of the classic presentation of tetralogy of Fallot.
3. A client with an exacerbation of asthma is prescribed albuterol. The nurse should assess the client for which common side effect of this medication?
- A. Tremors
- B. Nausea and vomiting
- C. Insomnia
- D. Dry mouth
Correct answer: A
Rationale: The correct answer is A: Tremors. Albuterol, a beta-agonist medication commonly used to treat asthma exacerbations, can lead to tremors as a side effect. Tremors result from the stimulation of beta-2 receptors in muscles, particularly in the hands. Nausea and vomiting (Choice B) are generally not common side effects of albuterol. Insomnia (Choice C) is less likely to occur with albuterol, as it is a stimulant and can cause alertness rather than sleep disturbances. Dry mouth (Choice D) is not a typical side effect associated with albuterol use.
4. A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?
- A. Montgomery straps
- B. Sterile gauze
- C. Adhesive tape
- D. Elastic bandages
Correct answer: A
Rationale: Montgomery straps are the correct choice in this scenario. They are specifically designed to secure dressings around drain sites, like Penrose drains, and are ideal for frequent dressing changes. Sterile gauze (Choice B) is commonly used for wound dressings but may not provide the best securement for drains. Adhesive tape (Choice C) can cause skin irritation and may not be suitable for securing drains. Elastic bandages (Choice D) are typically used for compression or support but are not appropriate for securing dressings around drain sites.
5. What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?
- A. Skin care around the stoma site
- B. The schedule for colostomy bag replacement
- C. Techniques for odor control
- D. Dietary modifications
Correct answer: A
Rationale: Correct answer: Skin care around the stoma site. Proper skin care around the stoma site is crucial for preventing skin irritation and infection, which are common issues for patients with new colostomies. While the schedule for colostomy bag replacement (Option B) is important, it is not the priority during initial discharge instructions. Techniques for odor control (Option C) are relevant but secondary to skin care for a new colostomy. Dietary modifications (Option D) may be discussed later but are not the priority at this stage.