assessment by the home health nurse of an older client who lives alone indicates that the client has chronic constipation daily medications include fu
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Nursing Elites

HESI LPN

CAT Exam Practice Test

1. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply)

Correct answer: C

Rationale: The correct answer is C. Increasing fluid intake is essential for managing constipation. Adequate hydration helps soften stool and promotes bowel movements. Choices A and B are incorrect as decreasing laxative use without medical advice and suggesting specific foods like oatmeal with stewed prunes may not be suitable for every individual with constipation. Choice D is also incorrect as while seeking help with meal preparation can indirectly aid in managing constipation, the immediate need is to increase fluid intake.

2. A 14-year-old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first?

Correct answer: A

Rationale: Autonomic dysreflexia is a potentially life-threatening emergency that can be triggered by a distended bladder in clients with spinal cord injuries at T-6 or above. The priority action is to determine if the urinary bladder is distended as this could be the cause of the symptoms observed in the adolescent. Flushing, sweating, bradycardia, and severe hypertension are classic signs of autonomic dysreflexia. Irrigating the urinary catheter, reviewing temperature graphs, or administering an antihypertensive agent are not the initial actions to take when suspecting autonomic dysreflexia.

3. The healthcare provider prescribed furosemide for a 4-year-old child with a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective?

Correct answer: B

Rationale: The correct answer is B. A daily weight decrease of 2 pounds (0.9 kg) is the most appropriate outcome to indicate the effectiveness of furosemide in a child with a ventricular septal defect. Furosemide is a diuretic medication that helps reduce fluid retention. Therefore, a decrease in weight reflects a reduction in fluid volume, which is the desired effect of furosemide. Choices A, C, and D are incorrect because changes in urine specific gravity, blood urea nitrogen (BUN) levels, and urinary output do not directly reflect the effectiveness of furosemide in this context.

4. A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.

5. An angry client screams at the emergency department triage nurse, “I’ve been waiting here for two hours! You and the staff are incompetent”. What is the best response for the nurse to make?

Correct answer: D

Rationale: Correct Answer: The best response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response demonstrates empathy and validates the client's feelings, helping to defuse the situation. Choice A is not the best response as it does not directly address the client's emotions or concerns. Choice B is inappropriate as it gives preferential treatment based on the client's behavior. Choice C, while true, does not acknowledge the client's frustration or offer empathy.

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