HESI CAT Exam Quizlet

Correct Answer: D

Rationale: The correct answer is D: Observation for and prevention of infection. Postoperative nursing care for a client with colon trauma primarily focuses on preventing infections. Clients with colon trauma are at high risk for infections due to the disruption of the intestinal barrier. Monitoring for signs of infection, maintaining proper wound care, administering antibiotics as prescribed, and implementing strict aseptic techniques are essential in preventing postoperative infections. Choices A, B, and C are incorrect because elevated coagulation studies, fistulas, and hyponatremia are not the primary concerns in the immediate postoperative period for a client with colon trauma.

Correct Answer: B

Rationale: Administering supplemental oxygen is the first priority to address low oxygen saturation and ease breathing. In a client with COPD experiencing difficulty breathing and anxiety with oxygen saturation at 88%, providing supplemental oxygen takes precedence over other actions. Placing the client in a high Fowler's position may help with breathing but does not address the immediate need for increased oxygenation. Performing a thorough respiratory assessment is important but should come after stabilizing the client's oxygen levels. Starting an IV infusion of normal saline is not the priority in this situation and does not directly address the client's respiratory distress.

Correct Answer: B

Rationale: The correct answer is B. A missed menstrual period could indicate a possible pregnancy-related issue, requiring urgent evaluation. Assessing the menstrual history in a female of reproductive age takes precedence in this scenario. Choice A, the pain scale rating, is important but not as urgent as evaluating the menstrual history. Choice C, reporting white curdy vaginal discharge, may suggest a vaginal infection but is not as critical as ruling out a potential pregnancy. Choice D, the history of irritable bowel syndrome, is relevant but not as crucial as determining pregnancy-related issues in this context.

Correct Answer: D

Rationale: Exploring the client's reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.

Correct Answer: B

Rationale: The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.