HESI LPN
HESI CAT
1. Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client’s dressing. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Sore throat when swallowing
- B. Tongue deviation to the left
- C. Palpable temporal pulses
- D. Temperature of 99.2°F (37.3°C)
Correct answer: B
Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.
2. The _________ is the hollow organ within females in which the embryo and fetus develop.
- A. placenta
- B. ovum
- C. uterus
- D. amniotic sac
Correct answer: C
Rationale: The correct answer is C: uterus. The uterus is the organ where the embryo implants and the fetus develops during pregnancy. The placenta (choice A) is an organ that develops during pregnancy and provides nutrients and oxygen to the fetus, but it is not the organ where the embryo and fetus physically develop. The ovum (choice B) is the female reproductive cell or egg that is fertilized by the sperm to form an embryo, but it is not the organ where the embryo and fetus develop. The amniotic sac (choice D) is a membrane filled with amniotic fluid that surrounds and protects the fetus, but it is not the organ where the embryo and fetus physically develop.
3. A client with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium. The nurse should instruct the client to report which potential side effect?
- A. Dry mouth
- B. Blurred vision
- C. Nausea
- D. Tachycardia
Correct answer: A
Rationale: The correct answer is A: Dry mouth. Tiotropium, a commonly prescribed medication for COPD, can cause dry mouth as a side effect. While it may not be severe, clients should report it if it becomes bothersome. Dry mouth is a common side effect of tiotropium due to its anticholinergic properties. Blurred vision, nausea, and tachycardia are not typically associated with tiotropium use in the context of COPD.
4. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?
- A. Dizziness when standing.
- B. Shuffling gait and hand tremors.
- C. Urinary retention.
- D. Fever of 102°F.
Correct answer: D
Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.
5. A client who had a hip replacement is being prepared for discharge. What should the nurse include in the discharge teaching to prevent hip dislocation?
- A. Avoid crossing your legs at the knees or ankles.
- B. Do not sleep on the side of the hip that was operated on.
- C. Sit in high chairs and keep your knees higher than your hips.
- D. Do not bend forward at the waist to pick up objects.
Correct answer: A
Rationale: The correct answer is A: 'Avoid crossing your legs at the knees or ankles.' Crossing legs at the knees or ankles can cause excessive stress on the new hip joint, leading to a risk of dislocation. Choice B is incorrect because sleeping on the side of the operated hip can also increase the risk of dislocation. Choice C is incorrect as sitting in low chairs with knees higher than hips is a recommended position to prevent hip dislocation. Choice D is incorrect because bending forward at the waist to pick up objects can strain the hip joint and increase the risk of dislocation.