HESI LPN
HESI CAT
1. The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
- A. Continue to measure the client’s vital signs every thirty minutes until the transfusion is complete
- B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
- C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
- D. Notify the nurse when the transfusion has finished, so further client assessment can be done
Correct answer: A
Rationale: The correct instruction for the UAP is to continue measuring the client’s vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.
2. Refers to the nurses in the local/national health departments or public schools:
- A. Public health nursing
- B. Public health nurse
- C. Registered midwives
- D. Registered nurses
Correct answer: B
Rationale: The correct term for nurses working in local/national health departments or public schools is 'public health nurse.' This term specifically refers to individual nurses in those settings. Choice A, 'Public health nursing,' is a broader term that refers to the field of nursing focused on improving community health. Choices C and D, 'Registered midwives' and 'Registered nurses,' do not specifically indicate the nurses working in local/national health departments or public schools, making them incorrect.
3. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?
- A. Altered sensory perception
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.
4. While assessing an older male client who takes psychotropic medications, the nurse observes uncontrollable hand movements and excessive blinking. Which information in the client's medical record should the nurse review?
- A. Prescription for lorazepam
- B. History of Parkinson's disease
- C. Screening for tardive dyskinesia
- D. Recent urine drug screen report
Correct answer: C
Rationale: The symptoms of uncontrollable hand movements and excessive blinking are indicative of tardive dyskinesia, a possible side effect of long-term use of psychotropic medications. Reviewing the screening for tardive dyskinesia is crucial to assess if these symptoms are related to the medication. Option A, the prescription for lorazepam, is less relevant as the focus should be on potential side effects rather than the specific medication. Option B, history of Parkinson's disease, is not directly related to the observed symptoms, which are more likely linked to medication side effects. Option D, recent urine drug screen report, is not as pertinent in this context compared to reviewing the screening for tardive dyskinesia.
5. Which procedure is used to detect neural tube defects such as spina bifida and certain chromosomal abnormalities?
- A. Artificial insemination
- B. Amniocentesis
- C. Endometriosis
- D. Alpha-fetoprotein (AFP) assay
Correct answer: D
Rationale: The correct answer is the Alpha-fetoprotein (AFP) assay. This blood test measures the level of AFP in a pregnant woman's blood, aiding in the detection of neural tube defects and certain chromosomal abnormalities in the fetus. Choice A, artificial insemination, is a method used to facilitate fertilization and is not related to detecting fetal abnormalities. Choice B, amniocentesis, involves collecting amniotic fluid for genetic testing, not directly measuring AFP levels. Choice C, endometriosis, is a medical condition involving abnormal tissue growth and is not a procedure for detecting fetal abnormalities. Therefore, the Alpha-fetoprotein (AFP) assay is the most appropriate option for detecting neural tube defects such as spina bifida and certain chromosomal abnormalities.