HESI LPN
HESI CAT Exam 2022
1. The healthcare provider receives a report on four clients who are complaining of increased pain. Which client requires immediate attention by the healthcare provider?
- A. Burning pain due to a Morton’s neuroma
- B. Sharp pain related to a crushed femur
- C. Paresthesia of fingers due to carpal tunnel syndrome
- D. Stinging pain related to plantar fasciitis
Correct answer: B
Rationale: Sharp pain related to a crushed femur indicates a severe condition and potential serious complications that require immediate attention. Crushed femur can lead to severe bleeding, nerve damage, or compartment syndrome, which are critical and life-threatening. The other choices, although painful, are less likely to present immediate life-threatening issues. Morton’s neuroma, carpal tunnel syndrome, and plantar fasciitis are painful conditions but are not typically associated with urgent, life-threatening complications like a crushed femur.
2. A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in the discharge teaching?
- A. Engage in physical exercise before eating to help decrease cholesterol levels.
- B. Avoid walking briskly in cold weather to prevent a decrease in cardiac output.
- C. Keep nitroglycerin in a light-colored plastic bottle and readily available.
- D. Avoid all isometric exercises, but walk regularly.
Correct answer: C
Rationale: The correct answer is to keep nitroglycerin in a light-colored container and readily available. Nitroglycerin should be protected from light to maintain its effectiveness. Option A is incorrect because physical exercise immediately before eating can trigger angina. Option B is incorrect as cold weather can exacerbate angina symptoms. Option D is incorrect as isometric exercises can increase the workload on the heart, which is not recommended for individuals with angina.
3. During a complete bed bath for a client, after removing the gown and placing a bath blanket over the body, which of the following areas should the nurse wash first?
- A. Face
- B. Feet
- C. Chest
- D. Arms
Correct answer: A
Rationale: When performing a complete bed bath, it is essential to wash the face first. Washing the face initially helps to maintain the client's privacy and comfort. Additionally, starting with the face prevents re-contamination of already cleaned areas. Washing the feet first (Choice B) is not ideal as it can lead to potential contamination of the upper body parts. Starting with the chest (Choice C) or arms (Choice D) is not recommended due to the risk of water dripping onto the client's face, causing discomfort and compromising privacy.
4. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?
- A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
- B. To prevent infection, the dressing should be kept dry to avoid excess moisture
- C. The skin incision should be kept moist to promote healing and prevent dryness
- D. The incision should be protected from fecal contamination by an intact dressing
Correct answer: D
Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
5. The nurse observes that a post-operative client's surgical wound has reddened edges and is oozing. What is the appropriate nursing action?
- A. Apply an antibiotic ointment
- B. Clean the wound with sterile saline
- C. Cover the wound with a sterile dressing
- D. Notify the surgeon immediately
Correct answer: D
Rationale: The correct action when a post-operative client's surgical wound has reddened edges and is oozing is to notify the surgeon immediately. Reddened, oozing wound edges can indicate an infection that requires prompt evaluation and intervention by the surgical team. Applying an antibiotic ointment (Choice A) without proper assessment and guidance can be inappropriate. Cleaning the wound with sterile saline (Choice B) and covering it with a sterile dressing (Choice C) may not address the potential infection adequately, and the client may require more specialized care that the surgeon can provide.