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. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?
- A. Explain that counseling will be provided to give her information about her cancer risk.
- B. Gather additional information about the client’s family history for all types of cancer.
- C. Offer assurance that there are a variety of effective treatments for breast cancer.
- D. Provide information about survival rates for women who have this genetic mutation.
Correct answer: A
Rationale: The correct answer is A because counseling will help the woman understand her risk and options for surveillance or preventive measures. At this point, it is crucial to address the woman's immediate concerns related to the BRCA1 gene mutation. Choice B is incorrect as the focus should be on the woman's individual risk due to the specific gene mutation she carries. Choice C is not the priority as treatment options come after assessing the risk and deciding on surveillance or preventive measures. Choice D is incorrect because discussing survival rates is not the immediate need for someone who has just received information about having a genetic mutation.
3. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Anxiety related to treatment plan
- B. Deficient knowledge of lifestyle changes
- C. Ineffective coping related to denial
- D. Decisional conflict due to stress
Correct answer: C
Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.
4. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first?
- A. Assist the client in conserving energy during daily activities
- B. Explain to the client that this could be a side effect of the medication
- C. Assess the client for pallor
- D. Encourage the client to maintain a balanced diet and hydration
Correct answer: C
Rationale: The correct first intervention for a client with rheumatoid arthritis reporting increasing fatigue is to assess the client for pallor. Fatigue can be a sign of anemia or other complications; assessing for pallor can help determine if anemia is the cause. Option A is incorrect as it does not address the underlying cause of fatigue. Option B assumes the cause without further assessment. Option D is important for overall health but assessing for pallor takes precedence to identify immediate issues related to fatigue.
5. To evaluate the medication’s effectiveness in a client with a respiratory tract infection, which laboratory values should the nurse monitor?
- A. White blood cell (WBC) count
- B. Sputum culture and sensitivity
- C. Droplet precautions
- D. Protective environment
Correct answer: A
Rationale: The correct answer is A: White blood cell (WBC) count. Monitoring the WBC count helps assess the overall response to infection and the effectiveness of the antibiotic. Sputum culture and sensitivity (choice B) are also important to confirm if the antibiotic is targeting the specific pathogen. Choices C and D, droplet precautions and protective environment, are not laboratory values but rather infection control measures that do not directly evaluate the medication's effectiveness in treating the infection.
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