HESI CAT Exam Quizlet

HESI LPN

1. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

A. An adolescent who works part-time in a paint factory
B. A 2-year-old who plays on aging outdoor playground equipment
C. A 10-year-old who has Type 1 diabetes mellitus
D. An 8-year-old who lives in a housing project

Correct answer: B

Rationale: Children playing on aging playground equipment are at higher risk of lead poisoning due to potential exposure from old paint. This is because deteriorating paint on older playground equipment may contain lead, which can be ingested by young children. Choices A, C, and D do not directly involve potential exposure to lead paint, making them less susceptible to lead poisoning compared to a child playing on aging playground equipment.

2. In what order should the nurse perform the steps of a surgical hand scrub prior to entering the operating room?

A. Rinse from the fingertips to the elbow
B. Scrape under the nails with a nail pick
C. Use a soapy brush to scrub the hands
D. Cleanse the arm with a lathered brush

Correct answer: B

Rationale: The correct order for performing a surgical hand scrub is to first scrape under the nails with a nail pick, then scrub the hands using a soapy brush, cleanse the arms, and finally rinse. This sequence ensures thorough cleaning and minimizes the risk of contamination. Choice A is incorrect because rinsing should be the final step, not the first. Choice C is incorrect as scrubbing the hands comes after scraping under the nails. Choice D is incorrect as cleansing the arms should follow hand scrubbing, not precede it.

3. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

A. Review the current treatment plan with the client
B. Inform the healthcare provider about the client’s behaviors
C. Determine if the client has PRN medication for anxiety
D. Explore the client’s reasons for wanting to be discharged

Correct answer: D

Rationale: Exploring the client’s reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.

4. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

A. Observe the appearance of the stool
B. Assess the client’s skin turgor
C. Review the client’s laboratory values
D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

5. A male client admitted three days ago with respiratory failure is intubated and receiving 40% oxygen per facemask. Currently, his temperature is 99°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

A. Exhibits adequate tissue perfusion
B. Remains free of injury
C. Remains free of infection
D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation is primarily measured by the client's ability to maintain an effective breathing pattern. This indicates that the client can adequately oxygenate and ventilate without the need for artificial airway support. Choices A, B, and C are important aspects of patient care but are not the primary outcomes to evaluate for successful extubation. Adequate tissue perfusion, freedom from injury, and prevention of infection are ongoing goals during the client's hospitalization but are not the immediate focus when considering extubation.