HESI LPN
HESI CAT
1. After the diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?
- A. Chest physiotherapy should be performed twice a day before a meal
- B. Energy should be conserved by scheduling minimally strenuous activities
- C. Administer a cough suppressant every 8 hours
- D. Maintain supplemental oxygen at 4 to 6 L/minute
Correct answer: A
Rationale: The correct answer is A. Chest physiotherapy is essential for maintaining pulmonary function in cystic fibrosis. It should be performed regularly, often twice daily, to clear mucus from the lungs. Choice B is incorrect because conserving energy does not directly promote pulmonary function. Choice C is incorrect as cough suppressants are not typically used to promote pulmonary function in cystic fibrosis. Choice D is incorrect as maintaining supplemental oxygen at 4 to 6 L/minute is not a standard home care treatment for promoting pulmonary functions in cystic fibrosis.
2. A client has just returned from surgery with an indwelling urinary catheter in place. What is the most important action for the nurse to take to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the catheter tubing is free of kinks.
- C. Clean the perineal area with antiseptic solution daily.
- D. Irrigate the catheter with normal saline every shift.
Correct answer: B
Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. Kinks in the tubing can lead to urine retention or obstruction, increasing the risk of infection. Changing the catheter every 72 hours is not necessary if there are no signs of infection or other issues. Cleaning the perineal area with antiseptic solution daily is important for hygiene but not the most critical action to prevent infection related to the catheter. Irrigating the catheter with normal saline every shift is not a routine practice and may increase the risk of introducing pathogens into the urinary system.
3. A young adult client was admitted 36 hours ago for a head injury that occurred as a result of a motorcycle accident. In the last 4 hours, the client’s urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?
- A. Obtain capillary blood samples for glucose every 2 hours
- B. Measure oral secretions suctioned during the last 4 hours
- C. Evaluate the urine osmolality and serum osmolality values
- D. Obtain blood pressure and assess for dependent edema
Correct answer: C
Rationale: The correct answer is to evaluate the urine osmolality and serum osmolality values. The increased urine output following a head injury could indicate diabetes insipidus, a condition characterized by excessive urination and extreme thirst. Evaluating osmolality is crucial for diagnosing diabetes insipidus. Choice A is incorrect because obtaining capillary blood samples for glucose every 2 hours is not the priority in this situation. Choice B is irrelevant to the client's current symptom of increased urine output. Choice D is also not the most appropriate intervention as the focus should be on assessing for a potential endocrine issue related to the increased urine output.
4. The practical nurse administered carbidopa-levodopa to a client diagnosed with Parkinson's disease. Which outcome by the client would indicate a therapeutic response?
- A. Decreased blood pressure
- B. Lessening of tremors
- C. Increased salivation
- D. Increased attention span
Correct answer: B
Rationale: The correct answer is B: Lessening of tremors. Carbidopa-levodopa increases the amount of levodopa to the CNS, providing more dopamine to the brain. Increased dopamine levels help alleviate Parkinson's symptoms such as tremors, involuntary movements, and gait abnormalities. Choices A, C, and D are incorrect as carbidopa-levodopa is not expected to have a direct effect on blood pressure, salivation, or attention span in the context of treating Parkinson's disease.
5. What should be monitored closely in a child receiving chemotherapy?
- A. Blood glucose levels
- B. White blood cell count
- C. Blood pressure
- D. Heart rate
Correct answer: B
Rationale: The correct answer is B: White blood cell count. During chemotherapy, it is crucial to monitor the white blood cell count closely to detect potential neutropenia (low white blood cell count) and the associated risk of infections. Monitoring blood glucose levels (Choice A) is important for diabetic management and not directly related to chemotherapy. Blood pressure (Choice C) and heart rate (Choice D) are essential vital signs to monitor but are not the primary focus when monitoring a child receiving chemotherapy.