HESI LPN
HESI CAT Exam 2022 Questions
Question 1 of 5
Which intervention should the nurse include in the plan of care for a patient with tetanus?
Correct Answer: C
Rationale: The correct intervention for a patient with tetanus is to minimize the amount of stimuli in the room. Tetanus can lead to muscle spasms and heightened sensitivity to stimuli, making it essential to reduce environmental triggers for the patient's comfort and safety. Opening window shades for natural light (
Choice
A) may exacerbate sensitivity to light and worsen symptoms. Encouraging coughing and deep breathing (
Choice
B) is not directly related to managing tetanus symptoms. While repositioning the patient every hour (
Choice
D) is important for preventing pressure ulcers, it is not the priority when managing tetanus, which requires a quiet, low-stimulus environment to minimize muscle spasms and discomfort.
Question 2 of 5
After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement?
Correct Answer: A
Rationale: Lethargy and difficulty arousing may indicate hypoglycemia, which should be assessed before other actions. Performing a finger stick glucose test is crucial to evaluate the child's blood sugar levels and address hypoglycemia promptly. Increasing the IV fluid flow rate is not indicated without knowing the glucose status. Reviewing 24-hour intake and output is important but not the priority when lethargy and difficulty arousing are present. Obtaining arterial blood gases is not the primary assessment needed in this situation.
Question 3 of 5
In what sequence should the nurse prepare the dose of insulin for a client whose finger stick glucose is 210 mg/dl and is receiving a sliding scale dose of short-acting insulin before breakfast?
Correct Answer: A
Rationale: The correct sequence for preparing a dose of insulin involves ensuring proper aseptic technique. First, clean the vial's rubber stopper with an alcohol swab to prevent contamination. Second, withdraw the correct dose of insulin to be administered. Lastly, inject air equal to the insulin dose into the vial to maintain proper pressure for withdrawing the medication. This sequence ensures the medication is prepared safely and accurately.
Choice A is correct as it follows this sequence.
Choices B, C, and D present incorrect sequences that may compromise patient safety by not following the correct aseptic technique.
Choice B injects air into the vial before withdrawing insulin, which is incorrect.
Choice C reverses the order of withdrawing insulin and injecting air.
Choice D withdraws the insulin before injecting air, which can affect the pressure inside the vial and lead to inaccurate dosing.
Question 4 of 5
After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, 'God has abandoned me. What did I do to deserve this?' Based on this response, the nurse decides to include which nursing problem in the client's plan of care?
Correct Answer: B
Rationale: The client's expression of feeling abandoned by God indicates spiritual distress, which is a significant issue that needs to be addressed in the plan of care. The individual is questioning their faith and seeking answers in a higher power, which aligns with spiritual distress.
Choices A, C, and D are not as directly related to the client's current emotional and spiritual struggle. Ineffective coping may be a consequence of spiritual distress, acute pain is not the primary concern in this scenario, and complicated grieving is premature as the client is still processing the diagnosis and seeking meaning.
Question 5 of 5
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?
Correct Answer: B
Rationale: Evaluating the newly hired UAP's competency by observing them deliver care is the most effective intervention to ensure they can provide safe and effective care. This approach directly assesses the UAP's actual performance and allows for immediate feedback. Option A, asking the most experienced UAP to partner with the newly hired one, may not guarantee that the new UAP is competent. Option C, reviewing the UAP's skills checklist and experience with the hiring person, does not provide a direct assessment of the UAP's current abilities. Option D, assigning the new UAP to less complex cases, does not address the need to evaluate their competency directly.