hesi cat exam quizlet HESI CAT Exam Quizlet - Nursing Elites
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Nursing Elites

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HESI CAT Exam Quizlet

1. 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.

2. The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client’s current GCS?

Correct answer: A

Rationale: A significant drop in GCS indicates a severe decline in neurological status, necessitating immediate communication with the healthcare provider. Notifying the healthcare provider allows for prompt evaluation and intervention to address the worsening condition. Choice B is incorrect because preparing the family for imminent death is premature and not supported by the information provided. Choice C is incorrect as the frequency of monitoring should be increased to every 15 minutes rather than every hour due to the significant drop in GCS. Choice D is incorrect because initiating CPR is not indicated based solely on a decreased GCS score.

3. Which instruction is most important for the client who receives a new prescription for risedronate sodium to treat osteoporosis?

Correct answer: A

Rationale: The most important instruction for a client receiving risedronate sodium to treat osteoporosis is to remain upright for 30 minutes after taking the medication. Risedronate sodium can cause esophageal irritation, and staying upright helps prevent this side effect. While increasing vitamin D intake, starting a low-impact exercise routine, and taking the medication with a full glass of water are all beneficial for managing osteoporosis, the immediate need is to prevent esophageal irritation caused by risedronate sodium.

4. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

5. A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

Correct answer: A

Rationale: The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.

Similar Questions

A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?
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Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?
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