HESI CAT Exam 2022

HESI LPN

1. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

A. The client has asymmetrical chest expansion
B. Percussion reveals dullness over the lung area
C. Bilateral breath sounds can be auscultated
D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

2. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and weak, thread pedal pulses. What action should the nurse take?

A. Document that an accurate oxygen saturation reading cannot be obtained
B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger
C. Increase the oxygen based on the client's breathing patterns and lung sounds
D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading

Correct answer: D

Rationale: Placing the oximeter clip on the earlobe is appropriate for clients with poor peripheral circulation, such as those with weak and thread pedal pulses due to bilateral below-the-knee amputations. This placement can provide a more accurate reading of oxygen saturation in such clients. Choice A is incorrect because alternative methods, such as earlobe placement, can be used to obtain accurate readings. Choice B is unnecessary and not related to obtaining an accurate oxygen saturation reading. Choice C is incorrect because increasing oxygen without assessing the oxygen saturation level first can be detrimental and is not based on evidence-based practice.

3. The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?

A. Debulk tumor to maintain patency of air passages
B. Relieve empyema after pneumonectomy
C. Prevent the formation of effusion fluid
D. Remove fluid from the intrapleural space

Correct answer: C

Rationale: The correct answer is C. Pleurodesis is a procedure used to prevent the re-accumulation of pleural effusion by creating adhesion between the pleurae. This helps prevent the formation of effusion fluid. Choices A, B, and D are incorrect because pleurodesis is not performed to debulk tumors, relieve empyema after pneumonectomy, or remove fluid from the intrapleural space. Understanding the purpose of pleurodesis is essential in providing accurate patient education and care.

4. A nurse working on an endocrine unit should see which client first?

A. An adolescent male with diabetes who is arguing about his insulin dose.
B. An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).
C. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour.
D. A client taking corticosteroids who has become disoriented in the last two hours.

Correct answer: B

Rationale: The correct answer is B. The client with Addison’s disease and a blood sugar level of 62mg/dl (3.44 mmol/l) is experiencing hypoglycemia, which can progress to adrenal crisis. This situation requires immediate attention to prevent further complications. Choices A, C, and D, although concerning, do not pose an immediate life-threatening risk compared to the client with Addison’s disease and hypoglycemia. The adolescent arguing about his insulin dose can be addressed after stabilizing the client with Addison’s disease. The adult with high blood sugar and increased urine output may have hyperglycemia but is not in immediate danger. The client taking corticosteroids who is disoriented needs evaluation but is not in an acute life-threatening condition as the client with hypoglycemia.

5. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

A. The client has asymmetrical chest wall expansion
B. The client complains of pain at the insertion site
C. The client's chest x-ray indicates decreased pleural effusion
D. The client's arterial blood gases show pH 7.35, PaO2 85, PaCO2 35, HCO3 26

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.