the nurse is caring for a client who had gastric bypass surgery yesterday which intervention is most important for the nurse to implement during the f

HESI LPN

CAT Exam Practice

1. The client had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

A. Insert an indwelling urinary catheter
B. Monitor for the appearance of an incisional hernia
C. Instruct the client to eat small frequent meals
D. Measure hourly urinary output

Correct answer: D

Rationale: Monitoring hourly urinary output is crucial during the first 24 postoperative hours to assess kidney function, fluid balance, and early detection of complications like dehydration or inadequate kidney perfusion. Inserting an indwelling urinary catheter is not routinely necessary after gastric bypass surgery unless there are specific indications. Monitoring for an incisional hernia is important but not the highest priority in the immediate postoperative period. Instructing the client to eat small frequent meals is essential for long-term dietary management after gastric bypass surgery, but not the most critical intervention during the initial 24 hours.

2. A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client’s dichotomous tendency?

A. I am glad you like me. Which nurse was acting aloof to you?
B. Tomorrow I will talk to that nurse about how you were treated last night.
C. What did the night nurse do that makes you think she is aloof?
D. I am happy that you are getting better and will be able to go home.

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.

3. A young adult client was admitted 36 hours ago for a head injury that occurred as a result of a motorcycle accident. In the last 4 hours, the client’s urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

A. Obtain capillary blood samples for glucose every 2 hours
B. Measure oral secretions suctioned during the last 4 hours
C. Evaluate the urine osmolality and serum osmolality values
D. Obtain blood pressure and assess for dependent edema

Correct answer: C

Rationale: The correct answer is to evaluate the urine osmolality and serum osmolality values. The increased urine output following a head injury could indicate diabetes insipidus, a condition characterized by excessive urination and extreme thirst. Evaluating osmolality is crucial for diagnosing diabetes insipidus. Choice A is incorrect because obtaining capillary blood samples for glucose every 2 hours is not the priority in this situation. Choice B is irrelevant to the client's current symptom of increased urine output. Choice D is also not the most appropriate intervention as the focus should be on assessing for a potential endocrine issue related to the increased urine output.

4. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

A. Explain that counseling will be provided to give her information about her cancer risk.
B. Gather additional information about the client’s family history for all types of cancer.
C. Offer assurance that there are a variety of effective treatments for breast cancer.
D. Provide information about survival rates for women who have this genetic mutation.

Correct answer: A

Rationale: The correct answer is A because counseling will help the woman understand her risk and options for surveillance or preventive measures. At this point, it is crucial to address the woman's immediate concerns related to the BRCA1 gene mutation. Choice B is incorrect as the focus should be on the woman's individual risk due to the specific gene mutation she carries. Choice C is not the priority as treatment options come after assessing the risk and deciding on surveillance or preventive measures. Choice D is incorrect because discussing survival rates is not the immediate need for someone who has just received information about having a genetic mutation.

5. In Duchenne muscular dystrophy, if a child has a Gower sign, what behavior should the nurse expect the child to exhibit?

A. Stands from sitting on the floor by using hands to walk up legs
B. Exhibits muscular atrophy of upper and lower extremities
C. Is unable to stand because of contractures of both hips
D. Walks with an unsteady gait and slaps feet on the floor

Correct answer: A

Rationale: The Gower sign is a characteristic finding in Duchenne muscular dystrophy where a child uses hands to walk up the legs when standing from a sitting position due to proximal muscle weakness. This behavior is indicative of the child trying to compensate for weak hip and thigh muscles. Choices B, C, and D are incorrect because they do not describe the specific behavior associated with the Gower sign. Muscular atrophy, contractures of both hips, and an unsteady gait with foot slapping are not directly related to the Gower sign.