HESI LPN
HESI CAT
1. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?
- A. Do not read with direct lighting for 6 weeks
- B. Avoid straining during stool passage, bending, or lifting heavy objects
- C. Irrigate conjunctiva with ophthalmic saline after applying antibiotic ointment
- D. Limit exposure to sunlight during the first 2 weeks while the cornea is healing
Correct answer: B
Rationale: The correct instruction to include in the discharge teaching for a client following cataract extraction is to 'Avoid straining during stool passage, bending, or lifting heavy objects.' This is crucial to prevent increased intraocular pressure after surgery, which can be harmful. Reading with direct lighting can strain the eyes but is not the primary concern post-cataract surgery. Irrigating the conjunctiva before applying antibiotic ointment is not a standard practice and may not be necessary. While limiting sunlight exposure is important for eye protection, it is secondary to avoiding activities that can increase intraocular pressure.
2. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
- A. Daily weight
- B. Vital signs
- C. Level of consciousness
- D. Bowel sounds
Correct answer: A
Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.
3. The healthcare provider is observing the way a patient walks. Which aspect is the healthcare provider assessing?
- A. Activity tolerance
- B. Body alignment
- C. Range of motion
- D. Gait
Correct answer: D
Rationale: When assessing the way a patient walks, the healthcare provider is evaluating the gait, which refers to a particular manner or style of walking. Body alignment pertains to the positioning of body parts in relation to one another, range of motion refers to the extent of movement of a joint, and activity tolerance relates to the ability to endure physical activities. In this scenario, observing the patient's walking pattern specifically focuses on gait assessment.
4. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse?
- A. Headache
- B. Pruritus
- C. Nausea
- D. Stridor
Correct answer: D
Rationale: Stridor is a high-pitched, noisy breathing sound that can indicate a serious condition like airway obstruction or a severe allergic reaction, necessitating immediate intervention to maintain the client's airway and prevent further complications. While headache, pruritus, and nausea are important to assess and manage, they are not as immediately life-threatening as stridor, which requires prompt attention to prevent respiratory compromise.
5. Before starting an intensive exercise program, what instruction is most important for the nurse to provide to the client?
- A. Be sure to have a complete physical examination before beginning your planned exercise program.
- B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.
- C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.
- D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
Correct answer: A
Rationale: Before starting an intensive exercise program, it is crucial for the client to have a complete physical examination. This examination ensures that the client is physically fit to engage in such activities and helps in identifying any underlying health issues that could be exacerbated by the exercise regimen. Choice B is incorrect because it focuses on stress levels related to eating habits rather than the importance of a physical examination for safety. Choice C is incorrect as exercise and stress management classes can complement each other rather than being mutually exclusive. Choice D is incorrect as monitoring weight loss, while important, is not as critical as ensuring the client's physical readiness for the exercise program.