HESI LPN
HESI CAT Exam 2022
1. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply)
- A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)
- B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
- D. Initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperative
Correct answer: B
Rationale: The correct answer is B. Obtaining postoperative vital signs for a client one day following unilateral knee arthroplasty is a task within the scope of practice for a practical nurse (PN) and contributes to the client's recovery. Administering insulin (Choice A) involves medication administration, which typically requires a higher level of nursing education. Performing daily surgical dressing changes (Choice C) after an abdominal hysterectomy involves wound care management that is usually beyond the scope of practice for a PN. Initiating patient-controlled analgesia pumps (Choice D) is a complex nursing intervention that requires specialized training and knowledge, exceeding the typical responsibilities of a PN.
2. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
- A. Liver damage
- B. Renal failure
- C. Gastric bleeding
- D. Heart attack
Correct answer: A
Rationale: Correct Answer: Large doses of acetaminophen can cause liver damage, which is a known adverse effect of the medication. Acetaminophen is metabolized in the liver, and excessive amounts can overwhelm the liver's ability to process it, leading to hepatotoxicity. Renal failure (Choice B) is not typically associated with acetaminophen use. Gastric bleeding (Choice C) is more commonly linked to nonsteroidal anti-inflammatory drugs (NSAIDs) rather than acetaminophen. Heart attack (Choice D) is not a recognized adverse effect of acetaminophen, which primarily affects the liver when taken in large amounts.
3. The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?
- A. Stop the procedure and tell the UAP to place the client in a Fowler's position
- B. Praise the UAP for doing the oral hygiene but encourage family participation
- C. Tell the UAP to continue because the unconscious client is positioned safely
- D. Enroll the UAP in a hospital education class on conducting safe client care
Correct answer: C
Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.
4. 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.
5. The healthcare provider is assessing a client with a history of congestive heart failure. Which assessment finding would be most concerning?
- A. Shortness of breath on exertion
- B. Weight gain of 2 pounds in a week
- C. Orthopnea
- D. Crackles in the lungs
Correct answer: D
Rationale: Crackles in the lungs are concerning because they indicate pulmonary congestion, a serious complication of congestive heart failure. The presence of crackles suggests fluid accumulation in the lungs, requiring immediate attention to prevent respiratory distress and worsening heart failure. While shortness of breath on exertion, weight gain, and orthopnea are common signs and symptoms of heart failure, crackles specifically point to acute pulmonary edema or worsening congestion, making them the most concerning finding in this scenario.