a client who is mechanically ventilated is receiving continuous enteral feedings through a nasogastric feeding tube to prevent aspiration which interv
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Nursing Elites

HESI LPN

HESI CAT Exam 2022

1. To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?

Correct answer: B

Rationale: The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.

2. An older male client with a history of type 1 diabetes has not felt well for the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Correct answer: D

Rationale: Administering IV fluids is crucial to address potential dehydration and electrolyte imbalances, especially if the client is unable to provide a clear history. Starting an IV infusion of normal saline will help rehydrate the client and address any electrolyte imbalances, which are common in clients with diabetes experiencing symptoms like abdominal cramping and vomiting. Obtaining a serum potassium level can be important but is not the priority when the client is showing signs of dehydration and confusion. Administering insulin should only be done after addressing hydration and electrolyte status. Assessing pupillary response to light is not the most critical action in this situation compared to addressing dehydration and potential electrolyte imbalances.

3. A 60-year-old male with type 2 diabetes mellitus tells the nurse that he is going to join a gym and start working out. Which information is most important for the nurse to obtain?

Correct answer: B

Rationale: The most important information for the nurse to obtain in this scenario is the presence of calf pain during exercise. Calf pain during exercise could indicate peripheral vascular issues, such as peripheral artery disease, which is crucial to address before starting an exercise program. High cholesterol levels (choice A) may be important but are not as immediately relevant as assessing for peripheral vascular issues. Average weight gain or loss (choice C) may provide some insight into the patient's overall health status but is not as critical as assessing for potential vascular complications. An exercise tolerance test with EKG results (choice D) may be valuable in assessing cardiovascular fitness but is not as crucial as evaluating for peripheral vascular issues given the patient's symptoms.

4. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out.” The nurse recognizes that the client is using which defense mechanism?

Correct answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

5. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Correct answer: A

Rationale: The correct answer is A because counseling will help the woman understand her risk and options for surveillance or preventive measures. At this point, it is crucial to address the woman's immediate concerns related to the BRCA1 gene mutation. Choice B is incorrect as the focus should be on the woman's individual risk due to the specific gene mutation she carries. Choice C is not the priority as treatment options come after assessing the risk and deciding on surveillance or preventive measures. Choice D is incorrect because discussing survival rates is not the immediate need for someone who has just received information about having a genetic mutation.

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