HESI LPN
HESI CAT Exam
1. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take?
- A. Tell the client he is required by law to inform his sexual partners of his HIV status
- B. Counsel the client about the importance of notifying his sexual partner
- C. Inform the wife of her health risk related to her husband's HIV results
- D. Report the client's status as a sexually transmitted case to the health department
Correct answer: B
Rationale: The nurse should counsel the client on the importance of notifying partners about HIV status while respecting confidentiality. Mandatory partner notification laws vary by jurisdiction, so option A cannot be universally applied. Breaching patient confidentiality, as suggested in option C, is unethical. Reporting the client's status to the health department without consent, as in option D, is not appropriate as HIV status is confidential information and is not automatically reported as a sexually transmitted case.
2. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:
- A. Establish an airway
- B. Call for assistance
- C. Check the client's pulse and blood pressure
- D. Perform CPR
Correct answer: A
Rationale: In a situation where a client is found unresponsive on the floor, the nurse's first priority is to establish an airway. This is crucial to ensure that the client can breathe adequately and receive oxygen. Without a patent airway, the client's oxygenation and ventilation may be compromised, leading to serious consequences. Calling for assistance is important, but establishing an airway takes precedence as it directly impacts the client's ability to breathe. Checking the client's pulse and blood pressure can be done after ensuring a clear airway. Performing CPR is not the immediate action needed unless the client's breathing and pulse are absent after the airway has been secured.
3. A 6-month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to
- A. Gently rub the skin with a cotton swab to relieve itching
- B. Place the favorite books and push-pull toys in the crib
- C. Check every few hours for the next day or 2 for swelling in the baby's feet
- D. Turn the baby with the abduction stabilizer bar every 2 hours
Correct answer: C
Rationale: The correct answer is to check every few hours for the next day or 2 for swelling in the baby's feet. Swelling in the baby's feet could indicate compromised circulation due to the cast, and frequent checks are necessary to ensure that there are no complications. Choices A, B, and D are incorrect because rubbing the skin with a cotton swab, placing favorite items in the crib, and turning the baby with the abduction stabilizer bar do not address the potential issue of compromised circulation and swelling in the baby's feet.
4. While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?
- A. Endotracheal cuff pressure greater than 25 cm H2O.
- B. Decreased lung compliance during ventilation.
- C. Bilateral crackles with increased secretions.
- D. Restless client who is biting the endotracheal tube.
Correct answer: D
Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.
5. What title should be given to this occupational health nurse job description?
- A. manager
- B. case manager
- C. health educator
- D. nurse consultant
Correct answer: D
Rationale: The correct title for this occupational health nurse job description is 'nurse consultant.' A nurse consultant is a registered professional nurse with expertise in occupational and environmental health nursing, effective communication skills, and good administrative and consultative abilities. Choice A, 'manager,' is incorrect as the job description does not primarily focus on managerial duties. Choice B, 'case manager,' is incorrect as it does not fully cover the scope of the described role. Choice C, 'health educator,' is incorrect as it does not encompass the administrative and consultative skills mentioned in the job description.