the nurse instructs an unlicensed assistive personnel uap to turn an immobilized elderly client with an indwelling urinary catheter every two hours wh
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Nursing Elites

HESI LPN

CAT Exam Practice

1. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

Correct answer: A

Rationale: The correct additional action the nurse should instruct the UAP to take each time the immobilized elderly client with an indwelling urinary catheter is turned is to empty the urinary drainage bag. This action helps to prevent backflow of urine, reduces the risk of infection, and prevents bladder distention, which are crucial for the client's comfort and health. Choices B, C, and D are incorrect as they are not directly related to the care of a client with an indwelling urinary catheter. Feeding a snack, offering oral fluids, or assessing breath sounds are important aspects of care but not the immediate action needed when turning a client with an indwelling urinary catheter to prevent complications.

2. 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.

3. In conducting the admission assessment for a client experiencing complications of long-term Parkinson’s disease, which question by the nurse provides the best information about disease progression?

Correct answer: C

Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson’s disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson’s disease but do not specifically address the aspect of disease progression related to freezing episodes.

4. Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?

Correct answer: C

Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.

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.

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