while assessing a client four hours post thoracentesis the nurse is unable to auscultate breath sounds on the right side of the chest what action shou
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Nursing Elites

HESI LPN

HESI CAT Exam 2024

1. While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first?

Correct answer: B

Rationale: The correct first action for the nurse to take in this situation is to assess the client’s vital signs and respiratory effort. It is crucial to promptly detect any immediate complications or changes in the client's condition. Instructing cough and deep breathing exercises (choice A) can be considered after further assessment. Administering oxygen (choice C) should be based on assessment findings and healthcare provider's orders. While documenting the findings (choice D) is essential, it should not be the first action when a potential issue with breath sounds is detected.

2. In conducting the admission assessment for a client experiencing complications of long-term Parkinson’s disease, which question by the nurse provides the best information about disease progression?

Correct answer: C

Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson’s disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson’s disease but do not specifically address the aspect of disease progression related to freezing episodes.

3. Which behavior is most likely to result in a breach of client confidentiality?

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

4. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?

Correct answer: B

Rationale: Children playing on aging playground equipment are at higher risk of lead poisoning due to potential exposure from old paint. This is because deteriorating paint on older playground equipment may contain lead, which can be ingested by young children. Choices A, C, and D do not directly involve potential exposure to lead paint, making them less susceptible to lead poisoning compared to a child playing on aging playground equipment.

5. The nurse is providing discharge teaching to a client who has undergone abdominal surgery. What instruction should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Avoid heavy lifting for at least 6 weeks.' After abdominal surgery, it is essential to avoid heavy lifting to prevent complications such as incisional hernias and support proper healing. Choice B, 'Limit fluid intake to reduce the risk of infection,' is incorrect because adequate fluid intake is necessary for wound healing and preventing dehydration. Choice C, 'Resume normal activities as soon as possible,' is incorrect as it may increase the risk of complications and delay healing. Choice D, 'Avoid driving for at least 2 weeks,' is incorrect as the restriction on driving may vary depending on the type of surgery and individual recovery.

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