the nurse is preparing to administer an oral antibiotic to a client with unilateral weakness ptosis mouth drooping and aspiration pneumonia what is th
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Nursing Elites

HESI LPN

HESI CAT Exam 2022

1. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

Correct answer: B

Rationale: The correct answer is to auscultate the client’s breath sounds. Assessing breath sounds is crucial in this scenario as it helps ensure that the client can safely swallow the oral antibiotic without aspirating. Unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia indicate potential swallowing difficulties, making it essential to assess breath sounds for any signs of respiratory issues. Asking about food preferences (choice A) may be relevant later but is not the priority before administering the medication. While obtaining vital signs (choice C) is important, assessing breath sounds takes precedence in this case. Determining which side of the body is weak (choice D) is not the priority assessment before administering the oral antibiotic.

2. When a UAP reports to the charge nurse that a client has a weak pulse with a rate of 44 beats per minute, what action should the charge nurse implement?

Correct answer: D

Rationale: The correct action for the charge nurse to implement is to notify the health care provider of the abnormal pulse rate and pulse volume. A weak pulse with bradycardia (pulse rate of 44 beats per minute) requires immediate follow-up to investigate potential underlying issues. In this situation, it is crucial to involve the healthcare provider for further assessment and intervention. Instructing the UAP to count the client's apical pulse rate for sixty seconds (Choice A) may delay necessary actions. Determining capillary refill time (Choice B) is not directly related to addressing a weak pulse, and assigning an LPN to assess an apical radial pulse deficit (Choice C) is not as urgent as involving the healthcare provider.

3. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?

Correct answer: D

Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.

4. The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Correct answer: B

Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.

5. The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client

Correct answer: A

Rationale: The correct answer is option A because this client is the most stable and requires less supervision. Assigning a client whose discharge has been delayed due to a postoperative infection to the newly graduate practical nurse would be appropriate during a busy day as they are likely to need routine care and monitoring rather than immediate intensive interventions. Option B involves a client with poorly controlled type 2 diabetes on a sliding scale for insulin administration, which requires close monitoring and prompt intervention, making it a less suitable assignment for a new graduate who may need more guidance. Option C, a newly admitted patient with a head injury requiring frequent assessments, would demand a higher level of vigilance and expertise, which may be challenging for a new graduate nurse to handle without adequate supervision. Option D, a patient receiving IV heparin regulated based on protocol, involves complex medication management that may be too advanced for a new graduate nurse without sufficient oversight.

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