HESI LPN
HESI CAT Exam 2022
1. The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?
- A. Evaluate the client’s intake and output
- B. Measure the client’s capillary blood glucose
- C. Consult with the dietitian about the client’s diet
- D. Apply a pulse oximeter to the client’s finger
Correct answer: B
Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client’s capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client’s diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.
2. When replacing a client's surgical dressing, what should the nurse do?
- A. Don sterile gloves to remove the old dressing
- B. Wash hands thoroughly before removing the old dressing
- C. Use sterile gloves to remove the old dressing
- D. Apply a new dressing before removing the old one
Correct answer: C
Rationale: When replacing a client's surgical dressing, the nurse should use sterile gloves to remove the old dressing. Sterile technique is essential to prevent introducing infection to the wound. Choice A is incorrect because clean gloves are not sufficient; sterile gloves are necessary to maintain asepsis. Choice B, washing hands, is an important step before and after the procedure to maintain hand hygiene, but sterile gloves are required during the dressing change. Choice D is incorrect because a new dressing should only be applied after the old one has been removed to prevent contamination and ensure proper wound care.
3. A client is complaining of a tingling sensation in the fingers, nose tip, and earlobes 24 hours after a total thyroidectomy. Which measure should the PN implement first?
- A. Apply sequential compression devices bilaterally
- B. Initiate prescribed L-thyroxine replacement therapy
- C. Obtain prescribed calcium gluconate for tetany
- D. Prepare for emergency tracheotomy at the bedside
Correct answer: C
Rationale: The correct answer is C: Obtain prescribed calcium gluconate for tetany. Tingling sensations post-thyroidectomy may indicate hypocalcemia, a potential complication that requires prompt treatment with calcium gluconate to prevent tetany. Initiating L-thyroxine replacement therapy (choice B) is important but not the first priority in this situation. Applying sequential compression devices (choice A) is not indicated for tingling sensations and does not address the potential complication of hypocalcemia. Preparing for an emergency tracheotomy (choice D) is not warranted based on the client's symptoms of tingling sensations.
4. A practical nurse (PN) is providing education to a client who is starting therapy with metformin for type 2 diabetes. What side effect should the client be instructed to report to the healthcare provider?
- A. Weight gain
- B. Hypoglycemia
- C. Muscle pain
- D. Nausea
Correct answer: D
Rationale: The correct answer is 'Nausea.' Nausea is a common side effect of metformin, especially when the medication is first started. It is essential for the client to report persistent or severe nausea to the healthcare provider for further evaluation and management. Weight gain (Choice A) is not a typical side effect of metformin; in fact, metformin is associated with weight loss or weight neutrality. Hypoglycemia (Choice B) is a potential side effect of some diabetes medications, but metformin does not typically cause hypoglycemia. Muscle pain (Choice C) is not a common side effect of metformin; it is more commonly associated with other medications like statins.
5. A client is taking levodopa-carbidopa for Parkinson's disease. The nurse should include which instruction when educating the client about this medication?
- A. Increase fluid intake to prevent dehydration.
- B. Take medication with food to improve absorption.
- C. Take medication at bedtime to avoid daytime drowsiness.
- D. It can cause nausea and dizziness.
Correct answer: A
Rationale: The correct instruction for a client taking levodopa-carbidopa for Parkinson's disease is to increase fluid intake to prevent dehydration. Levodopa-carbidopa should be taken with food to reduce gastrointestinal upset and improve absorption. Taking medication at bedtime is not necessary to avoid daytime drowsiness. It is crucial to prevent dehydration due to the medication's side effects. Choice B is incorrect because the medication should be taken with food, not at bedtime. Choice C is incorrect as taking the medication with food, rather than on an empty stomach, aids in absorption and reduces gastrointestinal side effects. Choice D is incorrect as it states the side effects of the medication rather than providing specific instructions on its administration.