HESI LPN
HESI CAT Exam 2022
1. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm?
- A. Assess IV site frequently for signs of extravasation
- B. Monitor capillary refill distal to the infusion site
- C. Apply a topical anesthetic at the infusion site for burning
- D. Explain that temporary burning at the IV site may occur
Correct answer: A
Rationale: The correct intervention the nurse should implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm is to assess the IV site frequently for signs of extravasation. Vesicants are agents that can cause tissue damage if they leak into the surrounding tissues. Monitoring for signs of extravasation such as swelling, pain, or redness is crucial to prevent tissue damage and ensure prompt intervention if extravasation occurs. Choices B, C, and D are incorrect because monitoring capillary refill, applying a topical anesthetic for burning, and explaining temporary burning do not directly address the risk of extravasation associated with vesicant chemotherapeutic agents.
2. A nurse is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate
- B. Maintain the space between the numerical dose and the unit of measure
- C. Note the dosage of insulin in units
- D. Use 'subcut' for indicating a subcutaneous injection
Correct answer: A
Rationale: The correct answer is A. The Institute for Safe Medication Practices recommends using the complete medication name magnesium sulfate when documenting medications to prevent misinterpretation. Choice B is incorrect because spaces should be maintained between the numerical dose and unit of measure for clarity. Choice C is incorrect as the standard notation for insulin dosage is in units, not using the letter U. Choice D is incorrect as the abbreviation for subcutaneous injection is commonly written as 'subcut' or 'subcutaneous,' not as SC.
3. A client is admitted with Atrial Fibrillation and is administered amiodarone (Cordarone). What therapeutic response should the nurse anticipate?
- A. Conversion of irregular heart rate to regular heart rhythm
- B. Pulse oximetry readings within normal range during activity
- C. Peripheral pulse points with adequate capillary refill
- D. Increase in exercise tolerance without shortness of breath
Correct answer: A
Rationale: The correct answer is A: Conversion of irregular heart rate to regular heart rhythm. Amiodarone is a medication commonly used to restore and maintain normal heart rhythm in clients with atrial fibrillation. It works by slowing down the electrical signals in the heart, helping to regulate the heartbeat. Choices B, C, and D are incorrect because they do not directly relate to the therapeutic response expected from administering amiodarone in a client with atrial fibrillation. Pulse oximetry readings, peripheral pulses, capillary refill, and exercise tolerance are important assessments but are not the primary therapeutic goal of using amiodarone in this situation.
4. When administering IV fluids to a client with a history of congestive heart failure (CHF), what is the nurse's primary concern?
- A. Monitoring for signs of fluid overload.
- B. Ensuring the client receives enough fluids to prevent dehydration.
- C. Preventing electrolyte imbalances.
- D. Maintaining the prescribed rate of fluid administration.
Correct answer: A
Rationale: The primary concern when administering IV fluids to a client with a history of congestive heart failure (CHF) is monitoring for signs of fluid overload. Clients with CHF are particularly vulnerable to fluid overload, which can exacerbate their condition. Signs of fluid overload include edema and difficulty breathing. Therefore, the nurse must closely monitor these signs to prevent worsening of the client's condition. Choices B, C, and D are incorrect because while ensuring hydration, preventing electrolyte imbalances, and maintaining the prescribed rate of fluid administration are important, they are secondary concerns compared to the critical task of monitoring for fluid overload in a client with CHF.
5. A client with a peptic ulcer is scheduled for a vagotomy and pyloroplasty. The nurse explains that the purpose of this surgery is to:
- A. Increase acid secretion
- B. Reduce acid secretion
- C. Promote gastric emptying
- D. Remove the ulcerated area
Correct answer: B
Rationale: The correct answer is B: "Reduce acid secretion." Vagotomy is performed to reduce acid secretion by cutting the vagus nerve, which stimulates acid production. Choices A, C, and D are incorrect. A vagotomy does not increase acid secretion, promote gastric emptying, or remove the ulcerated area. It specifically aims to decrease acid production to help in the healing of peptic ulcers.