a female client presents in the emergency department and tells the nurse that she was raped last night which question is most important for the nurse
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Nursing Elites

HESI LPN

HESI CAT Exam

1. In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

Correct answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

2. 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?

Correct answer: B

Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.

3. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take?

Correct answer: B

Rationale: The nurse should counsel the client on the importance of notifying partners about HIV status while respecting confidentiality. Mandatory partner notification laws vary by jurisdiction, so option A cannot be universally applied. Breaching patient confidentiality, as suggested in option C, is unethical. Reporting the client's status to the health department without consent, as in option D, is not appropriate as HIV status is confidential information and is not automatically reported as a sexually transmitted case.

4. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

5. The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus infection in infants who are starting to eat foods?

Correct answer: D

Rationale: The correct answer is D: Wash hands before any food preparation. Rotavirus is a highly contagious virus that can be prevented by maintaining proper hygiene. Washing hands before handling food can help prevent the spread of infections, including rotavirus. Choices A, B, and C are incorrect because while they are good practices for general hygiene and infant care, they are not specifically targeted at preventing rotavirus infection.

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