HESI LPN
HESI CAT Exam Test Bank
1. When implementing a disaster intervention plan, which intervention should the nurse implement first?
- A. Initiate the discharge of stable clients from hospital units
- B. Identify a command center where activities are coordinated
- C. Assess community safety needs impacted by the disaster
- D. Instruct all essential off-duty personnel to report to the facility
Correct answer: B
Rationale: When implementing a disaster intervention plan, the first step the nurse should take is to identify a command center where activities are coordinated. This step is crucial for ensuring an organized and effective disaster response. Option A, initiating the discharge of stable clients, is not a priority during the initial phase of disaster response. Option C, assessing community safety needs, usually follows setting up a command center. Option D, instructing off-duty personnel to report, may be necessary but is not the primary intervention at the beginning of a disaster situation.
2. The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?
- A. Change the dressing using a compression bandage
- B. Test fluid on the dressing for glucose
- C. Document the findings in the electronic medical record
- D. Mark drainage area with a pen and continue to monitor
Correct answer: B
Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.
3. After receiving report, which client should the nurse assess last?
- A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
- B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
- C. An older client with a distended abdomen and no drainage from the nasogastric tube
- D. An adult client with rectal tube draining clear pale red liquid drainage
Correct answer: D
Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.
4. When preparing the client for a thoracentesis, which action is essential for the nurse to take?
- A. Encourage the client to cough during the procedure
- B. Ask the client to void prior to the procedure
- C. Have the client lie in the prone position
- D. Determine if chest x-rays have been completed
Correct answer: B
Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.
5. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?
- A. Rented movies and borrowed books to use while passing time at home
- B. Discussing dietary restrictions with the nurse
- C. Arranging follow-up appointments with her oncologist
- D. Reporting to the nurse any new or worsening symptoms
Correct answer: D
Rationale: The correct answer is D because reporting any new or worsening symptoms to the nurse is crucial for the early detection of potential complications. This behavior shows that the client understands the importance of monitoring her health status post-chemotherapy treatment. Choices A, B, and C are incorrect because while renting movies, borrowing books, discussing dietary restrictions, and arranging follow-up appointments are all important aspects of care, the most critical factor immediately after chemotherapy is to monitor and report any new or worsening symptoms to healthcare providers.
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