CAT #2 review content
A client diagnosed with a small bowel obstruction vomits 300 mL of dark brown emesis
despite having a nasogastric tube set to low intermittent suction. Which action should the
nurse take first?
1. Brush your teeth and gums with a toothbrush. 2. Place client in a semi-Fowler position.
3. Assess nasogastric tube patency.
4. Evaluate function of suction equipment. - ANS-2
Placing the client in a semi-Fowler position reduces the risk of aspiration.
a client diagnosed with COPD experiences rapid a-fib. what med can the nurse give to the
patient - ANS-metroprolol
*okay to give in patients with COPD*
A client with schizophrenia claims to have heard voices and is telling the nurse that the
building is about to blow up. Which action will the nurse take first?
1. Escort the client to a quiet room.
2. Engage the client to focus on the nurse.
3. Provide an emergency dose of medication.
4. Call for help since the client is going to run. - ANS-2.
The nurse needs to work one-on-one with the client and help them focus on the nurse rather
than the hallucination. A client diagnosed with thrombocytopenia calls the clinic nurse. "I just
cut my skin while shaving; the bleeding won't stop even though I placed a bandage over the
cut," the client declares. Which response by the nurse is best?
1. "Hold pressure to the wound for 10 minutes and call back.
"2. "Go the emergency department immediately to be evaluated.
"3. "Come to the clinic in the morning for a platelet transfusion.
"4. "Bandage the wound tightly and elevate it on a pillow overnight." - ANS-1
It takes longer for this client to clot with fewer platelets and pressure should be applied
longer than for those who have a normal platelet count. The client should call back to let the
nurse know that the bleeding stopped or to receive further instructions.
A client may be developing side effects from an anticholinergic medication. Which question
does the nurse ask the client to further assess for side effects to this medication? (Select all
that apply.)
1. "Do you have blurred vision?"
2. "Does your mouth feel dry?"
3. "Do you feel like you have pins and needles? "4. "When was the last time you voided?"
5. "When was your last bowel movement?" - ANS-1,2,4,5
1) CORRECT - Anticholinergics cause dilatation of pupils and vision may be blurred.
2) CORRECT - Anticholinergics cause xerostomia or dryness of mouth.
3) Anticholinergics do not cause paresthesia.
4) CORRECT - Anticholinergics can cause urinary hesitancy and retention.
5) CORRECT - Anticholinergics can reduce bowel tone and motility and constipation may
occur.
A client recovering from total hip replacement surgery reports increased pain with
movement. Which nursing diagnosis is the most appropriate for this client?
A client diagnosed with a small bowel obstruction vomits 300 mL of dark brown emesis
despite having a nasogastric tube set to low intermittent suction. Which action should the
nurse take first?
1. Brush your teeth and gums with a toothbrush. 2. Place client in a semi-Fowler position.
3. Assess nasogastric tube patency.
4. Evaluate function of suction equipment. - ANS-2
Placing the client in a semi-Fowler position reduces the risk of aspiration.
a client diagnosed with COPD experiences rapid a-fib. what med can the nurse give to the
patient - ANS-metroprolol
*okay to give in patients with COPD*
A client with schizophrenia claims to have heard voices and is telling the nurse that the
building is about to blow up. Which action will the nurse take first?
1. Escort the client to a quiet room.
2. Engage the client to focus on the nurse.
3. Provide an emergency dose of medication.
4. Call for help since the client is going to run. - ANS-2.
The nurse needs to work one-on-one with the client and help them focus on the nurse rather
than the hallucination. A client diagnosed with thrombocytopenia calls the clinic nurse. "I just
cut my skin while shaving; the bleeding won't stop even though I placed a bandage over the
cut," the client declares. Which response by the nurse is best?
1. "Hold pressure to the wound for 10 minutes and call back.
"2. "Go the emergency department immediately to be evaluated.
"3. "Come to the clinic in the morning for a platelet transfusion.
"4. "Bandage the wound tightly and elevate it on a pillow overnight." - ANS-1
It takes longer for this client to clot with fewer platelets and pressure should be applied
longer than for those who have a normal platelet count. The client should call back to let the
nurse know that the bleeding stopped or to receive further instructions.
A client may be developing side effects from an anticholinergic medication. Which question
does the nurse ask the client to further assess for side effects to this medication? (Select all
that apply.)
1. "Do you have blurred vision?"
2. "Does your mouth feel dry?"
3. "Do you feel like you have pins and needles? "4. "When was the last time you voided?"
5. "When was your last bowel movement?" - ANS-1,2,4,5
1) CORRECT - Anticholinergics cause dilatation of pupils and vision may be blurred.
2) CORRECT - Anticholinergics cause xerostomia or dryness of mouth.
3) Anticholinergics do not cause paresthesia.
4) CORRECT - Anticholinergics can cause urinary hesitancy and retention.
5) CORRECT - Anticholinergics can reduce bowel tone and motility and constipation may
occur.
A client recovering from total hip replacement surgery reports increased pain with
movement. Which nursing diagnosis is the most appropriate for this client?
