HESI LPN
HESI CAT Exam Quizlet
1. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?
- A. Administer an anxiolytic
- B. Obtain a 12-lead electrocardiogram
- C. Stop the albuterol administration and restart in 30 minutes
- D. Educate the client about the side effects of albuterol
Correct answer: D
Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.
2. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.)
- A. Take an additional dose for signs of hyperglycemia
- B. Recognize signs and symptoms of hypoglycemia.
- C. Report persistent polyuria to the healthcare provider.
- D. Use sliding scale insulin for finger stick glucose elevation.
Correct answer: D
Rationale: The correct answer is D. Metformin does not require additional doses for hyperglycemia, and sliding scale insulin is not typically used with metformin. It is important for the client to recognize signs and symptoms of hypoglycemia, report persistent polyuria to the healthcare provider, and take the medication with meals. Teaching the client to use sliding scale insulin for finger stick glucose elevation is not appropriate in this case because metformin is the prescribed medication, and its mechanism of action differs from insulin therapy. The client should be educated on the importance of taking metformin with meals to reduce gastrointestinal side effects and to report any persistent polyuria, which could indicate poor blood sugar control.
3. The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client’s current GCS?
- A. Notify the healthcare provider of the GCS score
- B. Prepare the family for the client’s imminent death
- C. Monitor the client q1 hour for changes in the GCS score
- D. Begin cardiopulmonary resuscitation (CPR)
Correct answer: A
Rationale: A significant drop in GCS indicates a severe decline in neurological status, necessitating immediate communication with the healthcare provider. Notifying the healthcare provider allows for prompt evaluation and intervention to address the worsening condition. Choice B is incorrect because preparing the family for imminent death is premature and not supported by the information provided. Choice C is incorrect as the frequency of monitoring should be increased to every 15 minutes rather than every hour due to the significant drop in GCS. Choice D is incorrect because initiating CPR is not indicated based solely on a decreased GCS score.
4. An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?
- A. Apply bilateral eye patches while sleeping
- B. Use a whiteboard to communicate with the client
- C. Arrange food on the plate in a clockwise order
- D. Verbally identify oneself when entering the room
Correct answer: A
Rationale: The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.
5. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?
- A. Vanilla frozen yogurt
- B. Vegetable juice
- C. Clear beef broth
- D. Canned fruit cocktail
Correct answer: A
Rationale: The correct answer should be provided as choice E: Vanilla frozen yogurt. For a postoperative full liquid diet, the nurse should encourage the client to eat foods that are fully liquid and easy to digest. Vanilla frozen yogurt is a suitable choice as it provides calories and nutrients while being in a liquid form. Creamy peanut butter, vegetable juice, and canned fruit cocktail are not appropriate for a full liquid diet as they are not fully liquid and may not be easy to digest. Creamy peanut butter is solid, vegetable juice is not fully liquid, and canned fruit cocktail contains solid pieces.
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