HESI LPN
HESI CAT Exam Quizlet Questions
Question 1 of 5
What is the primary focus of postoperative nursing care for the client with colon trauma?
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.
Question 2 of 5
Following rectal surgery, a female client is very anxious about the pain she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication?
Correct Answer: C
Rationale: After rectal surgery, a stool softener is the most appropriate medication to help prevent pain and straining during defecation. Stool softeners work by increasing the water content of the stool, making it easier to pass without discomfort. Bulk-forming agents (
Choice
A) help add mass to the stool but may not address the immediate post-operative discomfort. Antianxiety agents (
Choice
B) would address the anxiety but not the physical discomfort. Stimulant cathartics (
Choice
D) are not recommended after rectal surgery as they can cause cramping and increased bowel movements, potentially exacerbating pain.
Question 3 of 5
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement?
Correct Answer: C
Rationale: The correct intervention for a client with dementia who is becoming increasingly confused at night and interfering with dressings and IV lines is to leave the lights on in the room at night. This intervention can help reduce confusion and disorientation.
Choice A is incorrect because changing the IV site gauge is not the priority in this situation.
Choice B is not necessary unless there are signs of infection or other complications at the abdominal incision site, which are not mentioned in the scenario.
Choice D should be avoided as using restraints should be a last resort and is not indicated in this case.
Question 4 of 5
A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client's dichotomous tendency?
Correct Answer: A
Rationale:
Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship.
Choice B focuses on a future action without addressing the immediate concern at hand.
Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of
Choice A.
Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
Question 5 of 5
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?
Correct Answer: A
Rationale: The correct instruction for the adult male client to follow when collecting a 24-hour urine specimen for a creatinine clearance test is to urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours. This method ensures proper collection for an accurate creatinine clearance measurement.
Choice B is incorrect as it describes a different procedure for a clean-catch urine sample, not suitable for creatinine clearance.
Choice C is incorrect as it suggests catheterization, which is not typically done for a creatinine clearance test, and it is not necessary for this procedure.
Choice D is incorrect as it does not follow the standard procedure for a 24-hour urine collection for creatinine clearance; the urine should be collected continuously over 24 hours, not at specified intervals.