an iv infusing in a clients left forearm becomes infiltrated after removing the iv which sites should the nurse select as possible site to insert anot
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Nursing Elites

HESI LPN

HESI CAT Exam 2024

1. After removing an IV that became infiltrated in the client’s left forearm, which site should the nurse select as a possible site to insert another IV catheter?

Correct answer: A

Rationale: The correct answer is A: Right hand. When an IV becomes infiltrated in the client's left forearm, it is essential to avoid the same side due to the risk of complications. Therefore, the right hand is a suitable alternative site for IV insertion. Choices B, C, and D are incorrect. Choosing the right forearm (B) would still be on the same side, which increases the risk of complications. The left hand (C) is not a preferred option immediately after an infiltration in the left forearm. The right subclavian (D) is an invasive site typically reserved for central line placement and not a first-line choice for IV insertion.

2. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first?

Correct answer: B

Rationale: The correct answer is B. A biophysical profile score of 5 out of 8 indicates potential fetal distress, necessitating immediate assessment to ensure the well-being of the fetus. The other options, while important, do not suggest an immediate threat to the fetus' health. The 38-week primigravida with contractions every 10 minutes may be in early labor, the 41-week multigravida scheduled for induction can be assessed after addressing the immediate concern, and the 36-week multigravida with serial blood pressure can be assessed after ensuring the client with potential fetal distress is stabilized.

3. A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?

Correct answer: A

Rationale: The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.

4. When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.

Correct answer: A

Rationale: The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.

5. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide?

Correct answer: B

Rationale: The correct answer is B: Drinking cranberry juice does not prevent urinary tract infections and should not be relied upon as a preventive measure. While cranberry juice is often associated with preventing UTIs, there is limited scientific evidence to support this claim. Choice A is incorrect because the sugar content in cranberry juice is not the main concern when discussing its role in preventing UTIs. Choice C is incorrect as there is no significant evidence to suggest cranberries affecting insulin levels. Choice D is incorrect as constipation is not a typical side effect of consuming cranberry juice; however, excessive consumption may lead to gastrointestinal discomfort.

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