HESI LPN
HESI CAT Exam
1. Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?
- A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
- B. A 15-year-old primigravida who has been self-supporting for the past 6 months
- C. The obstetrician explained a procedure that a neurologist will perform
- D. The client is illiterate but verbalizes understanding and consent for the procedure
Correct answer: D
Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.
2. 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.
3. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?
- A. The client has asymmetrical chest expansion
- B. Percussion reveals dullness over the lung area
- C. Bilateral breath sounds can be auscultated
- D. The client has been turned q2h
Correct answer: C
Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.
4. Which of the following is considered an internal disaster?
- A. A patient fall
- B. The massive spread of pneumonia
- C. A computer hacking episode
- D. Unexpected staff absences due to illness
Correct answer: C
Rationale: A computer hacking episode is considered an internal disaster as it disrupts the internal operations of the healthcare facility, compromising data security and potentially impacting patient care. Choices A, B, and D do not directly relate to internal disasters in a healthcare setting. A patient fall is a patient safety issue, the massive spread of pneumonia is a public health concern, and unexpected staff absences due to illness may affect staffing levels but are not typically classified as internal disasters.
5. What is the most common cause of vaginal bleeding immediately after birth?
- A. Uterine atony
- B. Genital lacerations
- C. Abnormal clotting mechanism
- D. Endometritis
Correct answer: A
Rationale: Vaginal bleeding immediately after birth is most often due to uterine atony, which is the failure of the uterus to contract following delivery. This results in inadequate compression of blood vessels at the placental site, leading to hemorrhage. Genital lacerations and abnormal clotting mechanisms can also cause bleeding but are less common immediately after birth compared to uterine atony. Endometritis, inflammation of the lining of the uterus, usually presents with symptoms like fever and pelvic pain rather than immediate postpartum bleeding.