HESI LPN
CAT Exam Practice Test
1. Which client’s vital signs indicate increased intracranial pressure (ICP) that the nurse should report to the healthcare provider?
- A. P 70, BP 120/60 mmHg; P 100, BP 90/60 mmHg; rapid respirations.
- B. P 55, BP 160/70 mmHg; P 50, BP 194/70 mmHg; irregular respirations.
- C. P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations.
- D. P 110, BP 130/70 mmHg; P 100, BP 110/70 mmHg; shallow respirations.
Correct answer: C
Rationale: Choice C is the correct answer. The vital signs presented (P 130, BP 190/90 mmHg; P 136, BP 200/100 mmHg; Kussmaul respirations) indicate increased intracranial pressure (ICP), which can be a serious condition requiring immediate medical attention. Kussmaul respirations are deep and labored breathing patterns associated with metabolic acidosis and can be a late sign of increased ICP. Choices A, B, and D do not demonstrate vital sign patterns consistent with increased ICP. Choice A shows variations in blood pressure and pulse rate but does not provide a clear indication of increased ICP. Choice B displays fluctuations in blood pressure and pulse rate with irregular respirations, but these vital signs do not specifically suggest increased ICP. Choice D presents relatively stable vital signs with shallow respirations, which do not align with the typical vital signs seen in increased ICP.
2. A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.
3. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system.
- B. Use alcohol-based hand sanitizer when leaving the client's room.
- C. Clean contaminated surfaces in the client's room with a phenol solution.
- D. Have family members wear a gown and gloves when visiting.
Correct answer: D
Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.
4. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?
- A. Pertussis, tetanus, polio, and measles
- B. Diphtheria, pertussis, tetanus, and polio
- C. Rubella, polio, tuberculosis, and pertussis
- D. Measles, mumps, rubella, and tuberculosis
Correct answer: B
Rationale: The correct answer is B: Diphtheria, pertussis, tetanus, and polio. By 11 months of age, infants should have received doses of these vaccines as part of the immunization schedule. Choice A is incorrect because measles is usually given later in the schedule. Choice C is incorrect as rubella is usually given as part of the MMR vaccine, not individually, and tuberculosis is not routinely given as a vaccine in early infancy. Choice D is incorrect because mumps is not part of the recommended vaccines at 11 months of age.
5. A healthcare professional is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. How many mL/hr should the IV infusion pump be set to deliver? (Round the answer to the nearest whole number. Do not use a trailing zero.)
- A. 100 mL/hr
- B. 150 mL/hr
- C. 75 mL/hr
- D. 50 mL/hr
Correct answer: A
Rationale: To infuse 1,000 mL over 10 hr, the IV pump should be set to deliver 100 mL/hr. This calculation is derived by dividing the total volume (1,000 mL) by the total time in hours (10 hr), resulting in the infusion rate of 100 mL/hr. Choices B, C, and D are incorrect as they do not accurately reflect the correct calculation for this scenario.