the nurse is preparing to administer an oral antibiotic to a client with unilateral weakness ptosis mouth drooping and aspiration pneumonia what is th
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Nursing Elites

HESI LPN

HESI CAT Exam 2022

1. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

2. An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct answer: A

Rationale: In a patient diagnosed with a pulmonary embolism, the most critical intervention is to monitor for signs of increased bleeding. Pulmonary embolism treatment often involves anticoagulation therapy, which increases the risk of bleeding. Monitoring for signs of bleeding such as bruising, petechiae, hematuria, or gastrointestinal bleeding is essential to prevent complications. Instructing on the use of incentive spirometry can be beneficial for preventing pulmonary complications but is not as urgent as monitoring for bleeding. Observing for confusion and restlessness may indicate hypoxia but is not the most crucial intervention in this scenario. Administering intravenous opioids for severe pain might be necessary but is not the priority compared to monitoring for bleeding, which is directly related to the treatment for pulmonary embolism.

3. The client has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client’s plan of care?

Correct answer: A

Rationale: The most important aspect to include in this client's plan of care is interventions to decrease emotional stress. Psoriasis, characterized by silvery scaling plaques on the skin, can be exacerbated by emotional stress. Managing stress is crucial in controlling the condition. Precautions about avoiding sunlight are important in psoriasis management, but emotional stress has a more significant impact. While omega-3 fatty acids may provide some benefits, stress management should take priority. Applying a corticosteroid cream may help with symptoms, but addressing emotional stress is crucial for long-term management of psoriasis.

4. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

5. The urinary drainage of a client with continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement?

Correct answer: A

Rationale: Increasing the irrigation rate can help clear any blood clots and reduce the redness in the urinary drainage. This intervention aims to improve the flushing of the bladder and potentially resolve the issue. Lowering the head of the bed would not directly address the red urinary drainage. Milking the catheter tubing is not recommended as it can cause trauma to the catheter or bladder, leading to further complications. While evaluating for fluid overload is an important nursing consideration, it does not directly address the immediate concern of redness in the urinary drainage, which requires a focused intervention to clear any blockages or clots in the system.

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