CAT Exam 1 Answers/Explanations (Graded A)

The nurse assess a pregnant client at 10 weeks gestation. Which finding is consistent with the gestational age of the fetus? - Answer- The fetal heartbeat may be detected as early as 10 weeks using a Doppler device. An unemancipated 15-year-old single parent of an infant brings the child to the clinic. The infant is diagnosed with an umbilical hernia and requires surgery. From whom does the nurse obtain surgical consent for the infant? - Answer- An unemancipated minor may sign the consent for medical treatment for the client's own custodial child. The nurse is providing care for a client who is prescribed amoxicillin-clavulanate for 14 days. Which finding indicates to the nurse that the client has developed a superinfection? - Answer- Whitish plaque in mouth indicates an oral fungal infection, a sign of superinfection The nurse provides care for a client with an oral temperature of 90 °F (32 °C). Which nursing diagnosis will the nurse use first to guide this client's care? - Answer- Severe hypothermia can lead to cardiac arrest The nurse provides care for an adolescent client who is diagnosed with meningitis but is otherwise previously healthy. The client is prescribed intravenous (IV) and oral fluids. The nurse closely monitors the client's fluid intake. Which serious complication does the nurse monitor this client for based on the current data? - Answer- Because of the inflammation of the meninges, the client is vulnerable to developing cerebral edema and increased intracranial pressure. The nurse plans care for an older adult client. Which intervention does the nurse implement to reduce this client's risk for falls? - Answer- A bedside commodes reduces the risk of rushing when needing to go to the bathroom A nurse who is in Generation X, works the night shift and requests more time off than other staff nurses. Which statement best explains a characteristic of this generation? - Answer- Individuals in this generation have a tendency to want work-life balance The nurse mentors a nursing student. The student asks which organization requires all clients to be assessed for pain. Which response by the nurse is correct? - Answer- 1) The NCSBN asserts that the scope of nursing includes a comprehensive assessment, but does not specifically identify pain. 2) The ANA developed standards for clinical practice, including those for assessment, but not specifically for pain. 3) CORRECT -The Joint Commission developed assessment standards, including that all clients be assessed for pain. 4) The NLN promotes valid, reliable guidelines and standards for clinical practice, but not specifically for pain. The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? - Answer- Family members can consent to organ donation after the client's death, even if the clients had not expressed a desire to have organs donated. The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions? - Answer- The suppository should be inserted a minimum of 2 inches for the medication to be effective The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first? - Answer- The red zone (50% or below peak flow) of the peak flow meter system signals an emergent situation. The nurse provides care for a post-operative client. Which conditions does early ambulation after surgery help prevent? (Select all that apply.) - Answer- 2) CORRECT - Ambulation reduces the risk of thromboembolism by increasing venous blood flow. 3) CORRECT - Ambulation reduces the risk of atelectasis by increasing the mobilization and expectoration of mucus. 4) CORRECT - Ambulation reduces the risk of paralytic ileus and promotes peristalsis. 5) CORRECT - Ambulation reduces the risk of pressure decubiti by reducing the time in bed and relieving pressure on bony prominences The nurse provides care to a client requiring a sterile dressing change. Which action will the nurse take when preparing the sterile field? - Answer- The outer 2.5 cm (1 in.) of the sterile field is not considered to be sterile. Therefore, the nurse should place all sterile items within 2.5 cm (1 in.) of the edge of the sterile field to ensure all items remain sterile. The nurse delegates tasks to nursing assistive personnel (NAP). Which statement will the nurse make that indicates adherence to the rights of delegation? (Select all that apply). - Answer- 1) It is beyond the scope of practice for NAP to evaluate the effectiveness of medication. 2) It is beyond the scope of practice for NAP to evaluate the effectiveness of nursing interventions. 3) CORRECT - The nurse is delegating an appropriate task and asking NAP to report the amount of urine output to the nurse.