the nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus dm after receiving the instructions the client exp
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Nursing Elites

HESI LPN

HESI CAT Exam

1. The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement?

Correct answer: B

Rationale: Providing the client with a printed list of medications and a schedule for administration is crucial to ensure adherence and understanding of the medication regimen at home. This intervention helps the client follow the prescribed treatment plan accurately. Choice A is not as essential since the client already understands when, how, and why to take the medications. Choice C is not a priority at this point as the client needs information for home medication management. Choice D, while helpful, is not the most important intervention compared to providing a clear list and schedule for medication administration.

2. A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents?

Correct answer: B

Rationale: The correct answer is B: Worming movements of the tongue. Worming movements of the tongue, known as tardive dyskinesia, are an irreversible side effect of antipsychotic medications. Tardive dyskinesia is characterized by involuntary, repetitive movements of the tongue, lips, face, trunk, and extremities. Cramping muscular pain (Choice A) is more indicative of dystonia, an extrapyramidal side effect that can be treated effectively with antiparkinsonian medications. Decreased tendon reflexes (Choice C) are not typically associated with irreversible side effects of antipsychotic agents. Dry oral mucous membranes (Choice D) are not specific to irreversible side effects of antipsychotic medications.

3. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?

Correct answer: B

Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.

4. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?

Correct answer: A

Rationale: The correct answer is A because in tertiary prevention, the focus is on managing complications and providing rehabilitation. Choice B is more aligned with primary prevention as it focuses on early diagnosis. Choice C's attendance in education sessions is not a direct indicator of managing complications. Choice D's improvement in knowledge does not directly measure the program's effectiveness in managing complications.

5. In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.

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