HESI LPN
HESI CAT Exam 2024
1. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?
- A. Administer regular insulin per sliding scale
- B. Cancel the client's dinner tray
- C. Give the client 4 ounces (120 mL) of orange juice
- D. Administer the next scheduled dose of metformin
Correct answer: A
Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.
2. The embryo and fetus develop within a protective _______ in the uterus.
- A. amniotic sac
- B. umbilical cord
- C. neural tube
- D. embryonic disk
Correct answer: A
Rationale: The correct answer is A, the amniotic sac. The amniotic sac is a fluid-filled structure that surrounds and protects the developing embryo and fetus in the uterus. It provides a cushion against external pressure, allows for movement and growth, and helps maintain a stable environment for the developing fetus. Choices B, C, and D are incorrect. The umbilical cord connects the fetus to the placenta and serves as a conduit for nutrients and waste; the neural tube is a structure that forms the central nervous system in early embryonic development; and the embryonic disk is a structure that forms during gastrulation, one of the early stages of embryonic development.
3. The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?
- A. Begin 0.9% saline solution intravenously as prescribed
- B. Administer regular insulin intravenously as prescribed
- C. Place child on a cardiac monitor
- D. Place child on a pulse oximetry monitor
Correct answer: A
Rationale: Initiating intravenous saline solution is the initial priority in managing diabetic ketoacidosis to address dehydration and electrolyte imbalances. Administering insulin without addressing dehydration first can lead to potential complications. While monitoring cardiac status and oxygen saturation are important, addressing the fluid and electrolyte imbalances takes precedence in the management of DKA.
4. You are working on a pediatric unit. Which toy or other diversional item or activity is most appropriate for your 18-month-old patient?
- A. Story books
- B. Beach balls
- C. An interactive play session with other children less than 2 years of age
- D. Pickup sticks
Correct answer: B
Rationale: A beach ball is appropriate for an 18-month-old as it is safe and can help with motor skills development. Choice A, storybooks, may not be suitable for this age group due to limited attention span. Choice C involves interaction with other children which may not always be feasible in a healthcare setting. Choice D, pickup sticks, poses a choking hazard and is not suitable for toddlers.
5. The client is preparing for discharge following treatment for heart failure. Which statement by the client indicates a need for further teaching?
- A. I will weigh myself every day at the same time.
- B. I will call my doctor if my legs swell more.
- C. I will take my water pill only when I feel short of breath.
- D. I will limit the amount of salt in my diet.
Correct answer: C
Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to manage fluid retention. Option A is correct as daily weight monitoring helps track for fluid retention. Option B is correct as worsening leg swelling should prompt contacting the healthcare provider. Option D is correct as limiting salt intake is essential in managing heart failure. Therefore, option C is the statement that indicates a need for further teaching.