which instruction should the nurse provide a pregnant client who is complaining of heartburn
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Nursing Elites

HESI LPN

CAT Exam Practice Test

1. What instruction should the nurse provide a pregnant client experiencing heartburn?

Correct answer: D

Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.

2. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?

Correct answer: C

Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.

3. Which action should the school nurse take first when conducting a screening for scoliosis?

Correct answer: C

Rationale: Inspecting for symmetrical shoulder height is a crucial initial step in screening for scoliosis. Asymmetry in shoulder height can indicate the presence of spinal curvature, which is a key indicator of scoliosis. This assessment is prioritized as it provides a visual clue to potential spinal abnormalities. Choices A, B, and D are not the first steps in scoliosis screening. Choice A involves a more detailed measurement that is not the primary visual indicator for scoliosis; choice B is not a primary indicator of scoliosis but can be used for further examination, and choice D is not directly related to identifying spinal curvature.

4. 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.

5. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

Correct answer: D

Rationale: The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.

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