HESI LPN
HESI CAT Exam 2022
1. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?
- A. Rising titers identify the etiology of certain neuro-sensory birth defects
- B. The screen determines the risk for inherited anomalies in the newborn
- C. The test identifies the correct antibiotic to give the newborn for an infection
- D. Exposure to infections that can cross the placenta cause a positive antibody titer
Correct answer: D
Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.
2. The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?
- A. Evaluate the client’s intake and output
- B. Measure the client’s capillary blood glucose
- C. Consult with the dietitian about the client’s diet
- D. Apply a pulse oximeter to the client’s finger
Correct answer: B
Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client’s capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client’s diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.
3. A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
- A. Ineffective airway clearance
- B. Altered nutrition less than body requirements
- C. Fluid volume excess
- D. Activity intolerance
Correct answer: A
Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.
4. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago.
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from dehydration caused by severe diarrhea
Correct answer: B
Rationale: The correct answer is B because the client who is ambulatory following coronary artery bypass graft surgery performed six days ago is stable enough for transfer compared to the other clients. Choice A should not be transferred as the client is still in the learning phase of self-administering insulin injections after being diagnosed with diabetes mellitus, requiring close monitoring. Choice C should not be transferred immediately after having a permanent pacemaker insertion as they need telemetry monitoring for any complications. Choice D should not be transferred as the client is experiencing syncopal episodes due to dehydration caused by severe diarrhea, requiring immediate intervention and close monitoring on the telemetry unit.
5. The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). Which intervention is most appropriate to include in the care plan?
- A. Instruct the client to use pursed-lip breathing
- B. Recommend a high-fat, low-carbohydrate diet
- C. Limit physical activity to prevent shortness of breath
- D. Encourage the client to drink large amounts of fluids
Correct answer: A
Rationale: The correct answer is A: Instruct the client to use pursed-lip breathing. Pursed-lip breathing helps improve ventilation and reduce shortness of breath in COPD clients. This technique involves inhaling slowly through the nose and exhaling through pursed lips. Choice B is incorrect because a high-fat, low-carbohydrate diet is not recommended for individuals with COPD as it can lead to weight gain and worsen respiratory function. Choice C is incorrect as limiting physical activity can lead to deconditioning and worsen COPD symptoms. Regular, moderate exercise is beneficial for individuals with COPD. Choice D is incorrect as excessive fluid intake can strain the heart in COPD clients. It is important to maintain adequate but not excessive fluid intake to prevent dehydration and maintain optimal lung function.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99