HESI LPN
HESI CAT
1. At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement?
- A. Administer insulin based on the sliding scale
- B. Assess the appearance of the foot wound
- C. Obtain antibiotic peak and trough levels
- D. Initiate hourly measurements of urine output
Correct answer: B
Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (Choice A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (Choice C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (Choice D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.
2. When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?
- A. I can concentrate best in the morning.
- B. I feel anxious about learning the process.
- C. I have a lot of questions about insulin.
- D. I am not sure if I can manage this at home.
Correct answer: A
Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.
3. In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?
- A. An infant with intermittent bulging anterior fontanel between crying episodes
- B. A toddler with severe deep abrasions covering over 98% of the body
- C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
- D. A school-age child with singed eyebrows and hair on the arms
Correct answer: B
Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.
4. During a routine monthly examination, a 5-month-old infant is brought to the pediatric clinic. What assessment finding should alert the nurse to notify the health care provider immediately?
- A. Temperature of 99.5°F
- B. Blood pressure of 75/48 mm Hg
- C. Heart rate of 100 beats per minute
- D. Respiratory rate of 50 breaths per minute
Correct answer: D
Rationale: A respiratory rate of 50 breaths per minute in a 5-month-old infant is higher than the expected range and may indicate respiratory distress. This finding is concerning and should prompt the nurse to notify the health care provider for further evaluation and intervention. A temperature of 99.5°F, blood pressure of 75/48 mm Hg, and heart rate of 100 beats per minute are within normal ranges for a 5-month-old infant. Elevated temperature may indicate a mild fever, which can be monitored. A blood pressure of 75/48 mm Hg is within the normal range for infants. A heart rate of 100 beats per minute is also within the expected range for a 5-month-old infant and does not typically require immediate notification of the health care provider.
5. A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?
- A. Allow the client to engage in any activity they choose.
- B. Provide a structured environment with reduced stimuli.
- C. Encourage the client to express their thoughts freely.
- D. Place the client in a room with another client for socialization.
Correct answer: B
Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.