HESI LPN
HESI CAT Exam 2022 Questions
Question 1 of 5
An older female client living in a low-income apartment complex tells the home health nurse that she is concerned about her 81-year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer?
Correct Answer: C
Rationale: The correct response is to provide the number for Adult Protective Services so the client can report any suspicion of elder abuse. This action allows for an official investigation into possible elder abuse or neglect, ensuring the neighbor's safety and well-being.
Choice A is incorrect because assuming dementia without evidence is premature and could lead to overlooking potential abuse.
Choice B is incorrect as the situation raises concerns about possible neglect or abuse, which should be reported promptly to the appropriate authorities.
Choice D is incorrect as it dismisses the importance of ensuring the safety and well-being of the neighbor in need.
Question 2 of 5
When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?
Correct Answer: B
Rationale: When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.
Question 3 of 5
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
Correct Answer: A
Rationale: The correct action for the nurse to take before leaving the room is to ensure that the knot can be quickly released. Using a half bow knot to attach the client's wrist restraints allows for quick release in case of an emergency. This is crucial for ensuring the safety of the client and complying with restraint policies. Tying the knot with a double turn or square knot (
Choice
B) would make it difficult to release quickly when needed. Moving the ties so the restraints are secured to the side rails (
Choice
C) does not address the immediate need for a quick release. Ensuring that the restraints are snug against the client's wrist (
Choice
D) may not be appropriate if the restraints need to be quickly removed for the client's safety.
Question 4 of 5
A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
Correct Answer: A
Rationale: In this scenario, the highest priority nursing problem for the postoperative client following a ureterolithotomy via a flank incision is ineffective airway clearance. After surgery, there is a risk of airway obstruction due to factors like anesthesia, positioning during surgery, or the presence of secretions. Maintaining a clear airway is crucial to prevent respiratory complications, such as atelectasis or pneumonia. Altered nutrition, fluid volume excess, and activity intolerance are important considerations but are secondary to the immediate threat of compromised airway clearance in the postoperative period.
Question 5 of 5
Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (
Choice
A) is important but not the priority in this scenario. Administering hydralazine (
Choice
C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (
Choice
D) is important for long-term management but is not the immediate action needed in this acute situation.