HESI LPN
HESI CAT Exam Quizlet
1. While assessing an older client’s fall risk, the client tells the nurse that they live at home alone and have never fallen. What action should the nurse take?
- A. Place the client on a high fall risk protocol solely based on their age
- B. Continue to obtain the client data needed to complete the fall risk survey
- C. Inform the client about falls occurring more often at the hospital than at home
- D. Record a minimal risk for falls based on the client's statement alone
Correct answer: B
Rationale: The correct action for the nurse in this scenario is to continue obtaining client data to complete the fall risk survey. This approach will help in conducting a comprehensive assessment of the client's risk factors. Placing the client on a high fall risk protocol solely based on age without a thorough assessment is premature and can lead to unnecessary interventions. Informing the client about falls in the hospital does not address the client's individual risk factors and is not relevant to the current assessment. Recording a minimal risk for falls based only on the client's statement may overlook other potential risk factors that need to be evaluated.
2. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
- A. The client with renal failure
- B. The client who is taking diuretics
- C. The client with hyperaldosteronism
- D. The client who is taking corticosteroids
Correct answer: B
Rationale: The correct answer is B. Clients taking diuretics are at risk for hyponatremia due to excessive sodium loss. In this scenario, a sodium level of 130 mEq/L indicates hyponatremia, which is commonly associated with diuretic use. Options A, C, and D are not the highest risk factors for developing low sodium levels in this context. Renal failure, hyperaldosteronism, and corticosteroid use are not directly linked to sodium loss as seen with diuretics.
3. When administering IV fluids to a dehydrated infant, what intervention is most important at this time?
- A. Continuing the prescribed flow rate
- B. Monitoring the intravenous drop rate
- C. Calculating the total necessary intake
- D. Maintaining the fluid at body temperature
Correct answer: B
Rationale: Monitoring the intravenous drop rate is crucial when administering IV fluids to ensure that the correct amount of fluids is delivered to the dehydrated infant. Choice A assumes the initial rate is correct without ongoing assessment. Choice C, while important, does not address the immediate need for monitoring the infusion rate. Choice D, maintaining the fluid at body temperature, is essential for comfort but is not as critical as ensuring the correct fluid delivery rate. By monitoring the intravenous drop rate, healthcare providers can adjust the flow as needed to prevent overhydration or underhydration, helping to manage the infant's fluid balance effectively.
4. A client with heart failure is receiving digoxin (Lanoxin). The nurse should monitor the client for which of the following signs of digoxin toxicity?
- A. Tachycardia
- B. Hypotension
- C. Bradycardia
- D. Hyperglycemia
Correct answer: C
Rationale: The correct answer is C: Bradycardia. Digoxin toxicity often presents with bradycardia, which is a common sign of toxicity associated with this medication. Tachycardia (Choice A) is not typically seen with digoxin toxicity. Hypotension (Choice B) can occur but is less specific to digoxin toxicity. Hyperglycemia (Choice D) is not a typical sign of digoxin toxicity. Therefore, monitoring for bradycardia is crucial in clients receiving digoxin to detect toxicity early.
5. A client is being taught how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client’s motivation to learn?
- A. The client’s belief that his needs will be met through education
- B. The nurse’s empathy regarding the client's self-injection
- C. The client seeking family approval by agreeing to a teaching plan
- D. The nurse explaining the need for education to the client
Correct answer: A
Rationale: The client's belief that his needs will be met through education is the most likely factor to increase motivation to learn. When individuals perceive that their educational efforts will directly benefit them, they are more motivated to engage in the learning process. Empathy from the nurse, seeking family approval, or the nurse explaining the need for education may not be as directly tied to the client's personal benefit and may not necessarily increase motivation to learn.