HESI LPN
HESI CAT Exam
1. The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?
- A. The appearance of the returning dialysate fluid is cloudy
- B. The client complains of slight shortness of breath during installation
- C. The amount of the returning dialysate fluid is greater than the amount instilled
- D. The client complains of abdominal fullness and cramping during instillation
Correct answer: A
Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.
2. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?
- A. Remove the cap and apply direct gentle pressure with the syringe
- B. Contact the healthcare provider regarding the need for a chest x-ray
- C. Cover the cap with tape and label the port as being obstructed
- D. Remove the catheter while applying gentle pressure at the insertion site
Correct answer: B
Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.
3. Which techniques should be used to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB)? Select all that apply.
- A. Observe for an intradermal bleed after the antigen is injected
- B. Select an ID site using the volar surface of the forearm
- C. Use a 26 or 27-gauge needle with a length of 1/4 to 5/8 inches on a 1 ml calibrated syringe
- D. Ensure that the needle is inserted into the skin with the bevel up
Correct answer: A
Rationale: Observing for an intradermal bleed after the antigen is injected is a proper technique for an ID injection. This is important to confirm the correct placement of the injection. Choice B is correct because the recommended site for an ID injection for a Mantoux test is the volar surface of the forearm. Choice C is incorrect because the standard needle size for an ID injection is usually 26 or 27 gauge with a length of 1/4 to 5/8 inches, not 25 gauge with a length of 1/2 inch. Choice D is incorrect because the needle should be inserted into the skin with the bevel facing up, not down.
4. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?
- A. Wear a dosimeter film badge when in the client’s room
- B. Spend 30 minutes at the bedside when providing direct care
- C. Change the linens every day after assisting with a bed bath
- D. Use gloves to remove the applicator if it is dislodged in the bed
Correct answer: A
Rationale: The correct action for the nurse to implement when caring for a client with a radioactive Cesium-loaded vaginal applicator during brachytherapy is to wear a dosimeter film badge when in the client’s room. Wearing a dosimeter badge is essential to monitor radiation exposure and ensure the safety of healthcare providers. Choice B is incorrect as the duration is not specified and unnecessary. Choice C is incorrect as changing linens daily does not directly relate to radiation safety. Choice D is incorrect as using gloves to remove the applicator if dislodged is important but not the primary action to monitor radiation exposure.
5. The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
- A. Low-grade fever
- B. Bruising of the skin
- C. Abdominal cramping
- D. Bloody emesis
Correct answer: D
Rationale: The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.
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