HESI LPN
HESI CAT Exam Test Bank
1. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home”. What response is best for the nurse to provide?
- A. Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely
- B. You seem to be concerned about the length of time it takes for Heparin to dissolve this clot
- C. Let me contact your healthcare provider to discuss the possibility of receiving IV heparin therapy at home
- D. Why are you so anxious to leave the hospital when you know you are not well enough yet?
Correct answer: A
Rationale: The correct response is A: 'Heparin prevents further clot formation, but your risk of bleeding needs to be monitored closely.' Heparin is an anticoagulant that prevents further clot formation, but it does not quickly dissolve existing clots. It is crucial for the nurse to educate the client about the purpose of heparin and the necessity for close monitoring of bleeding risks. Choice B is incorrect as it does not address the misunderstanding about heparin's mechanism of action. Choice C is incorrect as home administration of IV heparin therapy requires careful consideration and should not be suggested without a thorough assessment. Choice D is incorrect as it does not address the client's misconception about heparin's role in dissolving clots and instead focuses on the client's desire to leave the hospital.
2. A client recovering from abdominal surgery is on a clear liquid diet. The nurse should identify which of the following as the most appropriate food choice for this diet?
- A. Chicken noodle soup
- B. Grape juice
- C. Cream of wheat
- D. Vanilla pudding
Correct answer: B
Rationale: Grape juice is the most appropriate choice for a clear liquid diet as it is a transparent fluid that is easily digested. Clear liquid diets aim to provide fluids and electrolytes while being easy on the digestive system. Choices A, C, and D are not suitable for a clear liquid diet as they are not in liquid form or do not meet the criteria of being easily digestible for someone recovering from abdominal surgery. Chicken noodle soup, cream of wheat, and vanilla pudding are not considered clear liquids and may not be well-tolerated by a client who has undergone abdominal surgery.
3. The unlicensed assistive personnel (UAP) has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?
- A. Confirm that the gown is tied securely at the neck and waist
- B. Remind the UAP to wash hands frequently while in the room
- C. Assist the UAP with application of the face mask or face shield
- D. Help the UAP reposition the gown sleeve over the gloves edges
Correct answer: D
Rationale: Proper application of personal protective equipment (PPE) is crucial to maintain infection control. In this scenario, the nurse should help the UAP reposition the gown sleeve over the gloves' edges. This action ensures that the gown properly covers the gloves, reducing the risk of contamination. Choices A, B, and C are incorrect because the primary concern is to address the improper application of PPE by repositioning the gown sleeves over the gloves, not checking other aspects of PPE or reminding about hand hygiene.
4. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)
- A. Protect the medication from light exposure
- B. Monitor for changes in level of consciousness
- C. Observe for onset of generalized bruising or bleeding
- D. Perform ongoing assessment of respiratory status
Correct answer: D
Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.
5. When assessing a client's blood pressure and determining an auscultatory gap, which action should the nurse implement?
- A. Compare the palpated systolic blood pressure with the auscultated pressure
- B. Assess the client for lightheadedness upon standing
- C. Determine if an automated blood pressure reading is consistent with the manual reading
- D. Observe for changes in blood pressure between lying and sitting positions
Correct answer: A
Rationale: When an auscultatory gap is present, comparing the palpated systolic blood pressure with the auscultated pressure is crucial. This helps to accurately measure blood pressure and detect any discrepancies caused by the gap. Assessing for lightheadedness upon standing (choice B) is unrelated to addressing an auscultatory gap. Checking the consistency between automated and manual blood pressure readings (choice C) is important for validation but not specifically for managing an auscultatory gap. Observing blood pressure changes between lying and sitting positions (choice D) is relevant for orthostatic hypotension assessment but not for dealing with an auscultatory gap.
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