HESI LPN
HESI CAT Exam 2024
1. The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement?
- A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet
- B. Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses
- C. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed
- D. Document why the blood pressure cannot be accurately measured at the present time
Correct answer: D
Rationale: When a client cannot have their blood pressure measured due to specific circumstances such as casts on both arms, the nurse should document the reason why the blood pressure cannot be obtained accurately. This documentation is crucial for maintaining a clear record of the client's condition and for continuity of care. Advising the UAP to document the last blood pressure obtained (Choice A) does not address the current inability to measure the blood pressure. Estimating the blood pressure by assessing the pulse volume of radial pulses (Choice B) is not a reliable method for obtaining accurate blood pressure readings. Demonstrating how to palpate the popliteal pulse (Choice C) is irrelevant in this situation as it does not provide a solution for accurately measuring the blood pressure.
2. What is a primary intervention for a child with a suspected respiratory infection?
- A. Administer antiviral medications
- B. Increase fluid intake and rest
- C. Restrict all physical activity
- D. Provide high-dose vitamin supplements
Correct answer: B
Rationale: Increasing fluid intake and rest is a primary intervention for a child with a suspected respiratory infection because it helps support the body’s recovery and maintains hydration levels. Antiviral medications (Choice A) are only used for specific viral infections and are not routinely recommended for suspected respiratory infections. Restricting physical activity (Choice C) may be necessary in certain cases to prevent overexertion, but it is not a primary intervention. Providing high-dose vitamin supplements (Choice D) may support the immune system in general but is not a primary intervention for a suspected respiratory infection.
3. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar. Which of the following actions should the nurse take?
- A. Consult the medication reference book available on the unit.
- B. Administer the medication as ordered.
- C. Ask a colleague for information about the medication.
- D. Contact the provider to clarify the medication.
Correct answer: A
Rationale: When encountering an unfamiliar medication, the safest action for a nurse is to consult the medication reference book available on the unit. This resource provides accurate and detailed information about medications, including indications, dosages, side effects, and nursing considerations. Administering a medication without understanding it (choice B) can lead to medication errors and harm to the client. Asking a colleague for information (choice C) may not always provide accurate or up-to-date information. Contacting the provider (choice D) should be reserved for situations where immediate clarification is needed, but consulting the reference book is the initial step to gain knowledge and ensure safe medication administration.
4. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?
- A. Low oxygen levels are present in the blood.
- B. High levels of carbon dioxide have accumulated in the blood.
- C. Increased bicarbonate levels are causing alkalosis.
- D. Respiratory rate is increased, causing hyperventilation.
Correct answer: B
Rationale: High levels of carbon dioxide in the blood lead to respiratory acidosis due to inadequate ventilation. The correct answer is B. In respiratory acidosis, the accumulation of carbon dioxide in the blood occurs due to inadequate exhalation, leading to acidosis. Choice A is incorrect as low oxygen levels are related to hypoxemia, not respiratory acidosis. Choice C is incorrect as increased bicarbonate levels would lead to alkalosis, not acidosis. Choice D is incorrect as an increased respiratory rate causing hyperventilation would actually help decrease carbon dioxide levels, not lead to respiratory acidosis.
5. What is the best initial action for the nurse to take with a manic depressive male client who becomes loud and verbally aggressive towards a nurse?
- A. Have the staff escort the client to his room.
- B. Tell the client that his behavior will be recorded in his record.
- C. Redirect the client by asking him to engage in a game with peers.
- D. Review the medication record for an antipsychotic drug.
Correct answer: C
Rationale: In dealing with a manic depressive client who is being verbally aggressive, the best initial action for the nurse is to redirect the client by engaging him in a more constructive activity, such as playing card games with peers. This approach can help de-escalate the situation, shift the client's focus positively, and provide a distraction from the current behavior. Having the staff escort the client to his room may escalate the situation further. Threatening to record the behavior in his record is not likely to be effective in managing the immediate situation. Reviewing the medication record for an antipsychotic drug is important but would not be the best initial action in this scenario when the client is being verbally aggressive.