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Nursing Elites

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HESI CAT Exam Test Bank

1. 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.

2. The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?

Correct answer: C

Rationale: Elder abuse risk is higher in individuals who live with relatives and are on a fixed income as these factors can contribute to vulnerability. Living with relatives may expose the individual to potential abusive situations within the family dynamics. Additionally, being on a fixed income may limit financial independence and increase dependency on others, potentially leading to financial abuse. The other options, such as living alone and volunteering, residing in a nursing home, or living with a long-term spouse, do not inherently pose the same level of risk factors for elder abuse as living with relatives on a fixed income.

3. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

4. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture?

Correct answer: B

Rationale: Pyloric stenosis often leads to metabolic alkalosis due to the loss of gastric acid from vomiting. Metabolic acidosis would not be expected in pyloric stenosis as there is no excessive acid accumulation. Respiratory alkalosis and respiratory acidosis are not typically associated with pyloric stenosis, making them incorrect choices.

5. In conducting the admission assessment for a client experiencing complications of long-term Parkinson’s disease, which question by the nurse provides the best information about disease progression?

Correct answer: C

Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson’s disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson’s disease but do not specifically address the aspect of disease progression related to freezing episodes.

Similar Questions

In conducting the admission assessment for a client experiencing complications of long-term Parkinson’s disease, which question by the nurse provides the best information about disease progression?
The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube?
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?
The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?
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?
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