HESI LPN
HESI CAT Questions
Question 1 of 5
A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which action has the highest priority?
Correct Answer: C
Rationale: Assigning a private room has the highest priority in this scenario. It helps prevent the spread of H1N1 influenza to other patients and protects both the patient and others from potential infection. Obtaining specimens for cultures and monitoring vital signs are important but do not address the immediate need to prevent the spread of the virus. Administering Ringer's Lactate IV is not the priority in this case as it does not directly address the infectious nature of the condition.
Question 2 of 5
At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client's electronic health record, which priority nursing action should the nurse implement?
Correct Answer: B
Rationale: Assessing the appearance of the foot wound is the priority action in this scenario. This assessment is crucial to monitor for any signs of infection progression or complications related to the foot ulcer, especially in a client with diabetes mellitus. Administering insulin based on the sliding scale (
Choice
A) is important but not the immediate priority compared to assessing the foot wound. Obtaining antibiotic peak and trough levels (
Choice
C) is relevant but not as immediate as assessing the wound for signs of infection. Initiating hourly measurements of urine output (
Choice
D) is not the priority when compared to assessing the foot wound in a client with an infected foot ulcer.
Question 3 of 5
A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?
Correct Answer: A
Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.
Question 4 of 5
A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?
Correct Answer: A
Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF.
Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.
Question 5 of 5
When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?
Correct Answer: B
Rationale: The correct intervention is to schedule a follow-up appointment for an outpatient psychosocial assessment. This option addresses the client's concerns and provides support for managing stress and preventing future crises, which is crucial for the client's long-term care. Administering antianxiety medication before providing discharge instructions (
Choice
A) may not effectively address the underlying concerns. Obtaining a blood cortisol level before discharge (
Choice
C) is important but not the priority in this situation. Encouraging the client to remain in the hospital for a few more days (
Choice
D) is not the best course of action as it may not address the client's anxiety and could potentially lead to other issues.
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