HESI CAT

Questions 49

HESI LPN

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HESI CAT Questions

Question 1 of 5

After successful resuscitation, a client is given propranolol and transferred to the Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse?

Correct Answer: D

Rationale: The correct answer is D. A low respiratory rate of 10 breaths per minute is indicative of possible magnesium toxicity, which can be a serious condition requiring immediate intervention. It is a critical finding that needs prompt attention to prevent further complications. The other options are not as urgent: A - dark amber urine may indicate dehydration but does not require immediate intervention, B - serum calcium and magnesium levels are within normal limits, C - sinus rhythm and blood pressure values are also within normal range and do not require immediate action.

Question 2 of 5

Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client's dressing. Which additional assessment finding warrants immediate intervention by the nurse?

Correct Answer: B

Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2�F (37.3�C) is slightly elevated but does not suggest a critical issue related to the surgery.

Question 3 of 5

The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Correct Answer: D

Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.

Question 4 of 5

A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

Correct Answer: A

Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.

Question 5 of 5

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?

Correct Answer: A

Rationale: The correct instruction for the UAP is to continue measuring the client's vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.

Similar Questions

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

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