HESI LPN
HESI CAT Exam Test Bank Questions
Question 1 of 5
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
Correct Answer: B
Rationale: The correct answer is B. Reporting a weight gain of 2 pounds in 24 hours is crucial for detecting fluid retention or worsening heart failure. This rapid weight gain indicates possible fluid overload, which can be a sign of worsening HF. Option A is not as critical as the timing of weighing can vary. Option C is important for tracking trends but does not emphasize the significance of a sudden weight gain. Option D is relevant for managing HF but does not address the immediate need for reporting rapid weight gain.
Question 2 of 5
The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?
Correct Answer: A
Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice
B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice
C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice
D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.
Question 3 of 5
When washing soiled hands, what should the nurse do after wetting the hands and applying soap?
Correct Answer: A
Rationale: After wetting the hands and applying soap, the nurse should rub hands palm to palm. Rubbing hands palm to palm helps create friction and effectively clean the hands by spreading the soap and reaching all areas. Interlacing the fingers, drying hands with a paper towel, and turning off the water faucet should come after rubbing hands palm to palm in the handwashing process. Interlacing the fingers can be done to ensure the backs of the hands are cleaned, drying hands with a paper towel is the final step to ensure hands are dry, and turning off the water faucet helps save water.
Question 4 of 5
An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Administer a PRN dose of a muscle relaxant. Muscle spasms and pain might be relieved by muscle relaxants, which are appropriate before surgery.
Choice A is incorrect because the client is experiencing muscle spasms, not signs of deep vein thrombosis.
Choice C is not the most immediate action needed in this situation.
Choice D is incorrect because reducing the weight on the traction device would not directly address the muscle spasms and pain reported by the client.
Question 5 of 5
A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?
Correct Answer: B
Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (
Choice
A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (
Choice
C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client's allergies to non-drug substances (
Choice
D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.