HESI LPN
HESI CAT Exam 2024
1. The nurse working on a mental health unit is prioritizing nursing care activities due to a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened, and morning medications need to be prepared. Which plan is best for the nurse to implement?
- A. Wake all the clients and instruct them to go to the dining area for medication administration
- B. Explain to the clients that it will be necessary to cooperate until another RN arrives
- C. Ask the PN to administer medications as clients are awakened so both nurses are available
- D. Allow the clients to sleep until a third staff person can assist with unit activities
Correct answer: C
Rationale: The best plan for the nurse to implement is to ask the PN to administer medications as clients are awakened. This approach ensures that medication administration and client care are efficiently managed despite the staffing shortage. Option A is incorrect as it may disrupt the workflow and create unnecessary chaos. Option B is not the best choice as it does not address the immediate need for medication administration. Option D is not ideal as it delays client care until additional staff arrive, potentially compromising patient safety and timely medication administration.
2. What is the main purpose of the initial assessment of a child with a suspected fracture?
- A. To determine the type of fracture
- B. To check for potential complications
- C. To identify the cause of the injury
- D. To plan for long-term rehabilitation
Correct answer: B
Rationale: The main purpose of the initial assessment of a child with a suspected fracture is to check for potential complications, such as neurovascular impairment, and to ensure appropriate treatment. Choice A is incorrect because determining the type of fracture usually requires imaging studies like X-rays, which may not be part of the initial assessment. Choice C is incorrect because identifying the cause of the injury is important for the history-taking part but may not be the main purpose of the initial assessment. Choice D is incorrect because long-term rehabilitation planning typically occurs after the acute phase of fracture management.
3. Before administration of a stat dose of potassium chloride IV for a client with hypokalemia, what is the most important action for the nurse?
- A. Ensure the IV is flowing freely
- B. Mix the medication thoroughly
- C. Check the client’s electrolyte levels
- D. Obtain a baseline ECG
Correct answer: A
Rationale: The most crucial action for the nurse before administering a stat dose of potassium chloride IV to a client with hypokalemia is to ensure the IV is flowing freely. A freely flowing IV is essential to safely and effectively deliver potassium chloride, helping to prevent infusion-related issues. Checking the client's electrolyte levels or obtaining a baseline ECG may be important but are not the most critical actions before administering the medication. Mixing the medication thoroughly is not applicable in this scenario as potassium chloride is typically provided ready to use.
4. A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?
- A. Dizziness while standing
- B. Sinus tachycardia
- C. Lower back pain
- D. Absent patellar reflexes
Correct answer: D
Rationale: The correct answer is D: Absent patellar reflexes. Absent patellar reflexes can indicate magnesium toxicity, a serious condition that requires immediate intervention to prevent respiratory depression or cardiac arrest. Dizziness while standing (choice A) is common in pregnancy but does not specifically indicate magnesium toxicity. Sinus tachycardia (choice B) can be a normal response to magnesium sulfate but does not indicate toxicity. Lower back pain (choice C) is common in pregnancy and not specifically associated with magnesium toxicity.
5. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “What do you think you’re doing?” How should the nurse respond?
- A. “I cannot give you this medication until you calm down.”
- B. “This shot will help relieve the pain in your feet.”
- C. “Would you prefer to learn to administer your own shot?”
- D. “You will feel calmer and less jittery after this shot.”
Correct answer: B
Rationale: The correct response is to provide a relevant explanation to the client. Choice B, “This shot will help relieve the pain in your feet,” is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.