HESI LPN
HESI CAT Exam 2022
1. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and weak, thread pedal pulses. What action should the nurse take?
- A. Document that an accurate oxygen saturation reading cannot be obtained
- B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger
- C. Increase the oxygen based on the client's breathing patterns and lung sounds
- D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading
Correct answer: D
Rationale: Placing the oximeter clip on the earlobe is appropriate for clients with poor peripheral circulation, such as those with weak and thread pedal pulses due to bilateral below-the-knee amputations. This placement can provide a more accurate reading of oxygen saturation in such clients. Choice A is incorrect because alternative methods, such as earlobe placement, can be used to obtain accurate readings. Choice B is unnecessary and not related to obtaining an accurate oxygen saturation reading. Choice C is incorrect because increasing oxygen without assessing the oxygen saturation level first can be detrimental and is not based on evidence-based practice.
2. Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who
- A. is immobile on prescribed bedrest.
- B. has pressure ulcers on several toes.
- C. has diminished pedal pulse volume.
- D. is confused and trying to climb out of bed.
Correct answer: A
Rationale: The correct answer is A. Pneumatic compression devices are most beneficial for immobile clients on prescribed bedrest to prevent deep vein thrombosis. Applying these devices helps in promoting circulation and preventing blood clots. Choices B, C, and D do not specifically relate to the primary indication for pneumatic compression devices, making them incorrect. Pressure ulcers, diminished pedal pulse volume, and confusion with climbing out of bed may require different interventions or treatments.
3. A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client's arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?
- A. Vomiting, seizures, and loss of consciousness.
- B. Depression, fatigue, and dizziness.
- C. Hypotension, shallow respirations, and dilated pupils.
- D. Agitation, sweating, and abdominal cramps.
Correct answer: D
Rationale: Agitation, sweating, and abdominal cramps are early signs of narcotic withdrawal. Vomiting, seizures, and loss of consciousness (Option A) are more indicative of severe withdrawal or overdose symptoms. Depression, fatigue, and dizziness (Option B) are not typically early signs of narcotic withdrawal. Hypotension, shallow respirations, and dilated pupils (Option C) are more associated with opioid overdose rather than withdrawal. Monitoring for agitation, sweating, and abdominal cramps is crucial for managing narcotic withdrawal symptoms effectively.
4. A post-operative client is recovering from a total knee replacement and is prescribed patient-controlled analgesia (PCA). What is the primary advantage of PCA for managing post-operative pain?
- A. It allows for consistent pain control without overmedication.
- B. It eliminates the need for oral pain medication.
- C. It reduces the risk of opioid addiction.
- D. It requires less monitoring by nursing staff.
Correct answer: A
Rationale: The primary advantage of PCA for managing post-operative pain is that it allows the client to control the administration of pain medication, leading to consistent pain control without overmedication. Choice B is incorrect as PCA does not eliminate the need for oral pain medication; it supplements it. Choice C is incorrect because while PCA can help reduce opioid consumption, it does not directly reduce the risk of opioid addiction. Choice D is incorrect as PCA actually requires close monitoring by nursing staff to ensure proper use and prevent complications.
5. What information is most important for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia?
- A. Ensure the partner is screened for chlamydia
- B. Report any signs of liver dysfunction immediately
- C. Avoid consuming grapefruit juice while on this medication
- D. Use two forms of contraception while taking this drug
Correct answer: D
Rationale: The most important information for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia is to use two forms of contraception while taking this drug. Azithromycin can reduce the effectiveness of hormonal contraceptives, increasing the risk of pregnancy. It is crucial to convey this information to prevent unintended pregnancies. Option A is incorrect as the partner should be screened for chlamydia, not HIV, in this case. Option B is not the most important information to provide as liver dysfunction is a rare side effect of azithromycin. Option C is irrelevant as grapefruit juice does not interact with azithromycin. Therefore, the priority information to convey is the importance of using dual contraception to prevent pregnancy.