a male client with diabetes mellitus takes nphregular 7030 insulin before meals and azithromycin po daily using medication he brought from home when t
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Nursing Elites

HESI LPN

CAT Exam Practice

1. A male client with diabetes mellitus takes NPH/regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of azithromycin an hour before breakfast as instructed. What action should the nurse implement?

Correct answer: C

Rationale: Azithromycin should ideally be taken on an empty stomach; however, if taken after breakfast, it should not affect its efficacy. Instructing the client to eat his breakfast and take the azithromycin two hours after eating allows for proper absorption without compromising its effectiveness. Providing an antacid with azithromycin is not necessary in this case. Offering a new breakfast tray in an hour or skipping the dose is not the best course of action as it may lead to missed doses and potential effectiveness issues.

2. A 10-year-old who has terminal brain cancer asks the nurse, 'What will happen to my body when I die?' How should the nurse respond?

Correct answer: C

Rationale: The correct answer is C because it provides a truthful yet sensitive response to the child's question. Saying that the body will stop functioning and that there will be no more pain helps the child understand what to expect without unnecessary details or causing distress. Choice A is too technical and may not be suitable for a child. Choice B might give the impression of a peaceful passing, which may not always be the case. Choice D introduces the concept of feeling tired, which might not be accurate or helpful in this context.

3. An older client comes to the clinic with a family member. When the nurse attempts to take the client’s health history, the client does not respond to questions clearly. What action should the nurse implement first?

Correct answer: A

Rationale: The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.

4. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete before leaving the delivery room?

Correct answer: D

Rationale: Placing ID bands on the infant and mother is crucial to ensure correct identification and prevent mix-ups. This step is essential for maintaining proper identification of the newborn and the mother, facilitating safe care delivery. Before leaving the delivery room, ensuring proper identification is a priority to prevent any errors. Obtaining the infant's vital signs may be important but does not take precedence over ensuring correct identification. Observing the infant latching onto the breast is crucial for breastfeeding initiation but can be done after proper identification. Administering a vitamin K injection is also important but should not delay the immediate identification process.

5. After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol’s effectiveness?

Correct answer: A

Rationale: The best way to evaluate the effectiveness of a new fall prevention protocol is by comparing the number of falls that occurred before and after its implementation. This direct comparison helps in assessing the impact of the protocol on reducing fall rates. Choices B, C, and D do not directly measure the effectiveness of the protocol. Analyzing costs incurred (Choice B), conducting a chart review (Choice C), or consulting with a physical therapist (Choice D) may provide valuable information but do not specifically evaluate the protocol's effectiveness in preventing falls.

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