HESI LPN
HESI CAT Exam 2024
1. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?
- A. Instruct the client to perform cough and deep breathing exercises
- B. Assess the client’s vital signs and respiratory effort
- C. Administer oxygen via nasal cannula according to the PNR protocol
- D. Document assessment findings in the client’s medical record
Correct answer: B
Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.
2. When preparing to lift and reposition a patient, which action should the nurse take first?
- A. Assess weight to determine assistance needs.
- B. Position a drawsheet under the patient.
- C. Delegate the task to a nursing assistive personnel.
- D. Attempt to manually lift the patient alone before asking for assistance.
Correct answer: A
Rationale: The first action the nurse should take when preparing to lift and reposition a patient is to assess the patient's weight to determine the assistance needed. This step is crucial for the safety of both the patient and the nurse. Positioning a drawsheet under the patient (Choice B) is important for the comfort and safety during the repositioning process but should come after assessing the weight and assistance requirements. Delegating the task to a nursing assistive personnel (Choice C) can be considered once the assessment is complete and additional help is needed. Attempting to manually lift the patient alone before asking for assistance (Choice D) is unsafe and should never be done without first assessing the weight and determining the need for help.
3. How does omeprazole work in treating a peptic ulcer?
- A. Increasing the production of gastric acid
- B. Neutralizing stomach acid
- C. Coating the stomach lining
- D. Reducing gastric acid secretion
Correct answer: D
Rationale: Omeprazole is a proton pump inhibitor that works by reducing gastric acid secretion. By inhibiting the enzyme responsible for pumping acid into the stomach, omeprazole helps decrease the acidity level in the stomach, providing relief from peptic ulcers. Option A is incorrect because omeprazole does not increase gastric acid production; instead, it decreases it. Option B is incorrect as omeprazole does not neutralize existing stomach acid but rather reduces its secretion. Option C is incorrect as omeprazole does not coat the stomach lining but acts on reducing acid secretion.
4. What is the most common cause of vaginal bleeding immediately after birth?
- A. Uterine atony
- B. Genital lacerations
- C. Abnormal clotting mechanism
- D. Endometritis
Correct answer: A
Rationale: Vaginal bleeding immediately after birth is most often due to uterine atony, which is the failure of the uterus to contract following delivery. This results in inadequate compression of blood vessels at the placental site, leading to hemorrhage. Genital lacerations and abnormal clotting mechanisms can also cause bleeding but are less common immediately after birth compared to uterine atony. Endometritis, inflammation of the lining of the uterus, usually presents with symptoms like fever and pelvic pain rather than immediate postpartum bleeding.
5. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Allow liberal family visitation
- B. Keep an airway at the bedside
- C. Assess temperature every hour
- D. Monitor blood pressure, pulse, and respiration every 4 hours
Correct answer: B
Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.