HESI CAT Exam Test Bank

Questions 46

HESI LPN

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HESI LPN Test Bank

HESI CAT Exam Test Bank Questions

Question 1 of 5

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?

Correct Answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

Question 2 of 5

A man calls the hospital and asks to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and asks the nurse about her condition. What is the nurse's best response?

Correct Answer: C

Rationale: The nurse must adhere to confidentiality rules and cannot confirm the presence or condition of the client. Choice A is incorrect because disclosing the client's condition breaches confidentiality. Choice B is wrong as it reveals the client's room number, which is also a breach of confidentiality. Choice D is not the best response as it involves sharing information about the client without verifying the caller's identity or relationship to the client.

Question 3 of 5

The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?

Correct Answer: A

Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.

Question 4 of 5

The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?

Correct Answer: C

Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.

Question 5 of 5

When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

Correct Answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

Similar Questions

When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)
A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?
A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results shows that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?
While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

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