HESI LPN
HESI CAT
1. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
- A. Go to the emergency room to have blood drawn
- B. Prepare the medication using a new syringe
- C. Apply clean gloves before giving the medication
- D. Review the medical history in the client's chart
Correct answer: B
Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.
2. The nurse explains to the parents of a child with developmental hip dysplasia that the application of a Pavlik harness is necessary. In what position will the harness hold the child's femurs?
- A. Abduction
- B. Adduction
- C. Flexion
- D. Extension
Correct answer: A
Rationale: The correct answer is A: Abduction. The use of the Pavlik harness is to maintain the hips in abduction for 4 to 6 months to treat developmental hip dysplasia. This position helps in stabilizing the hip joint and promoting proper growth and development. Choices B, C, and D are incorrect because the Pavlik harness specifically aims to hold the child's femurs in abduction, not adduction, flexion, or extension.
3. While measuring a client’s oral temperature using an electronic thermometer, what action should the nurse take?
- A. Assist the client with oral hygiene before taking the temperature.
- B. Inquire whether the client has smoked in the last 30 minutes.
- C. Connect the red tip probe to the thermometer unit.
- D. Position the probe tip against the client’s buccal mucosa.
Correct answer: B
Rationale: The correct action for the nurse to take when measuring a client’s oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.
4. Joseph, 45 years of age, a community resident of Barangay 22-A, suddenly had 2 bouts of soft to almost watery stools after having taken his lunch. While observing his condition further at home and later deciding whether to refer him for medical treatment, you recommended that he boil a decoction for 15 minutes at low fire using 10-15 leaves of which medicinal plant?
- A. Bayabas
- B. Pancit pacitan
- C. Sambong
- D. Lagundi
Correct answer: A
Rationale: The correct answer is Bayabas (guava) leaves. Guava leaves are known for their anti-diarrheal properties, which can help alleviate Joseph's condition. Pancit pacitan, Sambong, and Lagundi are not commonly used for treating diarrhea and do not possess the same anti-diarrheal properties as guava leaves.
5. A client with type 2 diabetes mellitus is prescribed dulaglutide. The nurse should monitor for which potential adverse effect?
- A. Nausea
- B. Hypoglycemia
- C. Hyperglycemia
- D. Pancreatitis
Correct answer: A
Rationale: The correct answer is 'Nausea.' Dulaglutide, a medication commonly used in the management of type 2 diabetes, can lead to gastrointestinal side effects such as nausea. While hypoglycemia and hyperglycemia are potential concerns in diabetes management, they are not typically associated with dulaglutide use. Pancreatitis is a serious adverse effect of some diabetes medications, but it is not a common side effect of dulaglutide.