a client has produced the first of a series of sputum samples for cytology what action should the nurse implement
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Nursing Elites

HESI LPN

CAT Exam Practice Test

1. What action should the nurse take after a client produces the first of a series of sputum samples for cytology?

Correct answer: B

Rationale: The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.

2. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

Correct answer: A

Rationale: Asymmetrical chest wall expansion is a critical finding post-thoracentesis as it may suggest a pneumothorax, requiring immediate intervention to prevent further complications. The other options, such as pain at the insertion site (Choice B), decreased pleural effusion on chest x-ray (Choice C), and normal arterial blood gases within acceptable ranges (Choice D) do not indicate an immediate need for intervention like asymmetrical chest wall expansion does.

3. Which behavior is most likely to result in a breach of client confidentiality?

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

4. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?

Correct answer: B

Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.

5. A 10-month-old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the parent to assist in the diagnosis of cystic fibrosis (CF)?

Correct answer: A

Rationale: The correct answer is A. Salty skin is a common sign of cystic fibrosis due to high levels of sodium in sweat. Asking about the taste of the child's skin provides valuable information related to the diagnosis of CF. Choices B, C, and D are not helpful in diagnosing cystic fibrosis. A musty odor in urine is not a typical symptom of CF. Drinking cow's milk or bowel movement frequency are not specific to CF diagnosis.

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