while changing the pressure ulcer dressing of a client who is immobile the nurse notes that the boundary edges of the wound have increased before repo while changing the pressure ulcer dressing of a client who is immobile the nurse notes that the boundary edges of the wound have increased before repo
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Nursing Elites

HESI LPN

CAT Exam Practice

1. While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values?

Correct answer: D

Rationale: The correct answer is D: Albumin. Reviewing albumin levels is crucial in this situation because low albumin levels can impact wound healing and contribute to increased wound edges. Potassium (choice A) is not directly related to wound healing or wound edges. Platelets (choice B) are more related to blood clotting than wound healing. Creatinine (choice C) is related to kidney function, not specifically to wound healing or wound edges.

2. While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first?

Correct answer: C

Rationale: Notifying the charge nurse promptly is the priority when a bedfast client is dyspneic. Dyspnea can indicate a serious problem that requires immediate assessment and intervention. Contacting the charge nurse ensures timely assistance and appropriate actions to address the client's condition. Applying a pulse oximeter or measuring blood pressure may provide valuable data, but the priority is prompt communication with the charge nurse to ensure quick intervention. Observing pressure areas, while important for overall client care, is not the most immediate action needed when a client is experiencing dyspnea.

3. A child with type 1 diabetes mellitus is being discharged from the hospital. What is important for the nurse to include in the discharge teaching?

Correct answer: D

Rationale: Recognizing signs of hypoglycemia is essential for managing type 1 diabetes mellitus. Hypoglycemia, which occurs when blood glucose levels drop too low, can be dangerous and requires immediate intervention to prevent severe complications. Monitoring blood glucose levels more frequently than once a day, following a strict meal plan, and administering insulin only when blood glucose is high are important aspects of diabetes management but recognizing signs of hypoglycemia is crucial as it enables prompt action to prevent adverse outcomes.

4. What is an important consideration when administering medications to a child with a history of chronic renal failure?

Correct answer: B

Rationale: When administering medications to a child with chronic renal failure, it is crucial to consider adjustments in dosage due to altered drug metabolism. Children with chronic renal failure may have impaired drug excretion, leading to potential drug accumulation and toxicity. Increasing the frequency of medication administration (choice A) may not address the altered drug metabolism issue and could increase the risk of adverse effects. Avoiding all medications (choice C) is not practical or safe as some medications may be necessary for the child's health. Using only intravenous medications (choice D) is not always required and may not be the best route of administration for all medications needed.

5. What is the primary nursing intervention that the practical nurse should perform before administering ampicillin to a client diagnosed with a urinary tract infection?

Correct answer: A

Rationale: The correct answer is to obtain a clean-catch urine specimen. Before administering ampicillin to a client with a urinary tract infection, it is crucial to collect a urine specimen to determine the causative organism and evaluate the effectiveness of pharmacological therapy. Assessing the urine pH for acidity (choice B) is not the primary intervention needed before administering ampicillin. Inserting an indwelling catheter (choice C) is invasive and not necessary unless indicated for specific reasons. Assessing for complaints of dysuria (choice D) is important but does not take precedence over obtaining a urine specimen for proper diagnosis and treatment.

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