the nurse is assigned to care for four surgical clients after receiving report which client should the nurse see first
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HESI CAT Exam Test Bank

1. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Correct answer: B

Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.

2. To evaluate the medication’s effectiveness in a client with a respiratory tract infection, which laboratory values should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A: White blood cell (WBC) count. Monitoring the WBC count helps assess the overall response to infection and the effectiveness of the antibiotic. Sputum culture and sensitivity (choice B) are also important to confirm if the antibiotic is targeting the specific pathogen. Choices C and D, droplet precautions and protective environment, are not laboratory values but rather infection control measures that do not directly evaluate the medication's effectiveness in treating the infection.

3. 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)

Correct answer: D

Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.

4. Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first?

Correct answer: B

Rationale: In a client with a C-5 spinal cord injury experiencing flushing and a headache, the priority intervention is to assess the client's blood pressure every 15 minutes. These symptoms could indicate autonomic dysreflexia, a potentially life-threatening condition. Assessing the blood pressure is crucial to identify and address this emergency situation promptly. Checking for kinks or obstructions in the Foley tubing (Choice A) is important but not the priority in this scenario. Administering hydralazine (Choice C) without knowing the blood pressure could be harmful as it may lead to a sudden drop in blood pressure. Educating the client on recognizing symptoms of dysreflexia (Choice D) is important for long-term management but is not the immediate action needed in this acute situation.

5. Which behavior is most likely to result in a breach of client confidentiality?

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

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