HESI LPN
HESI CAT Exam
1. The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?
- A. Remove old dressing using clean gloves. Discard gloves with old dressing
- B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
- C. Apply sterile gauze dressing to wound area
- D. Secure dressing with tape
Correct answer: A
Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.
2. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?
- A. Swelling and redness in the affected leg
- B. Pain in the affected leg
- C. Warmth and tenderness in the affected leg
- D. A positive Homans' sign
Correct answer: D
Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.
3. Which cardiac defects are associated with tetralogy of Fallot?
- A. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis
- B. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle
- C. Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
- D. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy, and an atrial septal defect
Correct answer: C
Rationale: The correct answer is C: Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta are the cardiac defects associated with Tetralogy of Fallot. In Tetralogy of Fallot, these specific abnormalities contribute to the classic features of the condition. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of Tetralogy of Fallot. Choice B describes transposition of the great arteries, not Tetralogy of Fallot. Choice D mentions an altered connection between the pulmonary artery and the aorta, which is not a defining characteristic of Tetralogy of Fallot.
4. The PN administered darbepoetin alfa to a client with chronic kidney disease (CKD). Which serum laboratory value should the PN monitor to assess the effectiveness of this drug?
- A. Calcium
- B. Phosphorus
- C. Hemoglobin
- D. White blood cell count
Correct answer: C
Rationale: Darbepoetin alfa is used to stimulate red blood cell production in clients with CKD. Monitoring hemoglobin levels is essential to assess the effectiveness of the treatment and to adjust the dosage to avoid complications such as hypertension or thrombosis. Monitoring calcium (Choice A), phosphorus (Choice B), or white blood cell count (Choice D) is not directly related to the effectiveness of darbepoetin alfa in treating anemia associated with CKD.
5. A client with a history of seizures is prescribed valproic acid. The nurse should monitor for which potential adverse effect?
- A. Liver toxicity
- B. Kidney stones
- C. Weight gain
- D. Pancreatitis
Correct answer: A
Rationale: Corrected Valproic acid is known to cause liver toxicity as a potential adverse effect. Regular monitoring of liver function tests is crucial to detect any signs of liver damage early on and prevent serious complications. Kidney stones, weight gain, and pancreatitis are not typically associated with valproic acid use, making them incorrect choices in this scenario.