HESI LPN
HESI CAT Exam 2024
1. What nursing intervention is most important to implement after a client has completed a myelogram?
- A. Lie-sit-stand blood pressure measurement
- B. Abdominal assessment for distention and bowel sounds
- C. Neurovascular assessment of lower extremities
- D. Assessment of skin temperature and turgor
Correct answer: C
Rationale: The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.
2. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?
- A. “I will set my water heater at 130°F.”
- B. “Once my baby can sit up, they should be safe in the bathtub.”
- C. “I will place my baby on their stomach to sleep.”
- D. “Once my infant starts to push up, I will remove the mobile from over the crib.”
Correct answer: D
Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.
3. Which of the following is the most effective way to prevent the spread of infection in a healthcare setting?
- A. Using sterile gloves
- B. Wearing a face mask
- C. Performing hand hygiene
- D. Using disposable equipment
Correct answer: C
Rationale: Performing hand hygiene is the most effective way to prevent the spread of infection in a healthcare setting. Hand hygiene helps remove pathogens that could be transmitted through direct contact, making it a crucial practice in infection control. While using sterile gloves and disposable equipment are important in certain situations, they do not address the potential transmission of pathogens through direct contact, unlike hand hygiene. Wearing a face mask is important for respiratory precautions but may not be as effective as hand hygiene in preventing the spread of infections through direct contact.
4. While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?
- A. Use gloves to inspect the hair.
- B. Apply a lindane-based shampoo immediately.
- C. Shave the patient's hair off.
- D. Ignore the movement and continue.
Correct answer: A
Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.
5. A client with stage IV lung cancer is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child’s wedding.” Based on the Kubler-Ross model, which stage of grief is the client experiencing?
- A. Anger
- B. Denial
- C. Bargaining
- D. Acceptance
Correct answer: C
Rationale: The client is in the bargaining stage of grief according to the Kubler-Ross model. In this stage, individuals negotiate for more time to achieve specific goals or fulfill desires. The client's statement about quitting smoking to attend their child's wedding reflects this bargaining behavior. Anger (choice A) is characterized by frustration and resentment, denial (choice B) involves avoidance of reality, and acceptance (choice D) signifies coming to terms with the situation, none of which align with the client's current mindset of bargaining.