HESI LPN
HESI CAT Exam 2022
1. To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?
- A. Verify the feeding tube position with a daily chest x-ray
- B. Maintain head of bed elevated while enteral feeding is infusing
- C. Check feeding tube placement with air bolus prior to use
- D. Aspirate stomach contents every 4 hours to assess residuals
Correct answer: B
Rationale: The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.
2. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement?
- A. Wear a dosimeter film badge when in the client’s room
- B. Spend 30 minutes at the bedside when providing direct care
- C. Change the linens every day after assisting with a bed bath
- D. Use gloves to remove the applicator if it is dislodged in the bed
Correct answer: A
Rationale: The correct action for the nurse to implement when caring for a client with a radioactive Cesium-loaded vaginal applicator during brachytherapy is to wear a dosimeter film badge when in the client’s room. Wearing a dosimeter badge is essential to monitor radiation exposure and ensure the safety of healthcare providers. Choice B is incorrect as the duration is not specified and unnecessary. Choice C is incorrect as changing linens daily does not directly relate to radiation safety. Choice D is incorrect as using gloves to remove the applicator if dislodged is important but not the primary action to monitor radiation exposure.
3. A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?
- A. Ask the most experienced UAP on the team to partner with the newly hired UAP.
- B. Evaluate the newly hired UAP’s level of competency by observing the UAP deliver care.
- C. Review the UAP’s skills checklist and experience with the person who hired the UAP.
- D. Assign the newly hired UAP to clients who require the least complex level of care.
Correct answer: B
Rationale: Evaluating the newly hired UAP’s competency by observing them deliver care is the most effective intervention to ensure they can provide safe and effective care. This approach directly assesses the UAP's actual performance and allows for immediate feedback. Option A, asking the most experienced UAP to partner with the newly hired one, may not guarantee that the new UAP is competent. Option C, reviewing the UAP’s skills checklist and experience with the hiring person, does not provide a direct assessment of the UAP's current abilities. Option D, assigning the new UAP to less complex cases, does not address the need to evaluate their competency directly.
4. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child’s urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?
- A. Perform a finger stick glucose test
- B. Increase the IV fluid flow rate
- C. Review 24-hour intake and output
- D. Obtain arterial blood gases
Correct answer: A
Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.
5. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hour?
- A. 18
- B. 27
- C. 36
- D. 45
Correct answer: D
Rationale: The infusion rate is calculated based on the concentration of lidocaine and the prescribed rate of infusion. First, convert lidocaine's weight to milligrams (2 grams = 2000 mg). Then, use the formula: (Total volume in ml * dose in mg) / 60 minutes. For this case, (500 ml * 2000 mg) / 60 minutes = 45 ml/hour. Therefore, the correct answer is D. Choices A, B, and C are incorrect as they do not reflect the accurate calculation based on the provided concentration and infusion rate.
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