a new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the torch screen tes
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Nursing Elites

HESI LPN

HESI CAT Exam 2022

1. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to the mother's inquiry?

Correct answer: D

Rationale: The TORCH screen test is used to detect infections that can affect the newborn by showing if there was exposure to these infections. Choice A is incorrect because the TORCH screen test is not specifically for identifying the etiology of neuro-sensory birth defects. Choice B is incorrect because the test does not determine the risk for inherited anomalies. Choice C is incorrect because the test is not used to identify the correct antibiotic for an infection, but rather to detect infections that may have affected the newborn.

2. 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.

3. Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?

Correct answer: B

Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.

4. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

5. The client with a mechanical valve replacement understands the discharge teaching when the client makes which statement?

Correct answer: A

Rationale: The correct answer is A. Clients with mechanical valve replacements need to take prophylactic antibiotics before dental procedures to prevent endocarditis. Choice B is incorrect because even with a new valve, heart medications may still be necessary to manage the condition. Choice C is incorrect because mechanical valves typically do not need replacement as frequently as within 10 years. Choice D is incorrect because hearing a clicking sound near the heart could indicate valve malfunction, not just the need to notify the healthcare provider.

Similar Questions

An older male client with a history of type 1 diabetes has not felt well for the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?
A 20-year-old male client is diagnosed with Ewing’s sarcoma following an examination for a knee injury. Which instruction is most important for the nurse to provide the client?
A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?
The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?
For a client with pneumonia, the prescription states, “Oxygen at liters/min per nasal cannula PRN difficult breathing.” Which nursing intervention is effective in preventing oxygen toxicity?

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