HESI LPN
HESI CAT Exam Questions
Question 1 of 5
The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?
Correct Answer: A
Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level.
Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.
Question 2 of 5
The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first?
Correct Answer: D
Rationale: In this situation, the priority action for the nurse is to change the client's position. Altering the client's position can help facilitate better fluid drainage in peritoneal dialysis, potentially resolving the issue without the need for more invasive interventions. Continuing to monitor intake and output (
Choice
A) is important but addressing the immediate drainage issue takes precedence. Checking blood pressure and serum bicarbonate levels (
Choice
B) is not directly related to the observed output flow discrepancy. Irrigating the dialysis catheter (
Choice
C) should not be the initial action as it is more invasive and should be considered only if repositioning does not resolve the issue.
Question 3 of 5
The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?
Correct Answer: D
Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment.
Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected.
Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation.
Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.
Question 4 of 5
After a motor vehicle collision, a client is admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement?
Correct Answer: C
Rationale: In a client with acute adrenal insufficiency (Addisonian crisis) following a motor vehicle collision, the priority intervention is to administer IV corticosteroid replacement. This is crucial to manage the crisis by replacing the deficient cortisol. Determining serum glucose levels (
Choice
A) may be important but is not the immediate priority in this situation. Withholding potassium additives to IV fluids (
Choice
B) is not indicated and may exacerbate electrolyte imbalances. Initiating IV vasopressors (
Choice
D) is not the primary treatment for acute adrenal insufficiency and should be reserved for managing hypotension that is unresponsive to corticosteroid therapy.
Question 5 of 5
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt/minute should the nurse regulate the infusion? (Enter a numeric value only. If rounding is required, round to the nearest whole number.)
Correct Answer: A
Rationale:
To calculate the rate: (1000 ml / 4 hours) = 250 ml/hour; (250 ml/hour) / (60 minutes/hour) = 4.17 ml/minute; (4.17 ml/minute) * (10 gtt/ml) = 41.7 gtt/minute, rounded to 42 gtt/minute.
Therefore, the nurse should regulate the infusion at 42 gtt/minute to deliver the prescribed fluid challenge accurately. The other choices are incorrect as they do not reflect the correct calculation based on the given information.