CAT Exam Preparation
A client diagnosed with thrombocytopenia calls the clinic nurse. The client states, "I just cut
my skin while shaving; the bleeding won't stop even though I placed a bandage over the
cut." Which response by the nurse is best? - ANS-If the client holds pressure for a
significant amount of time but continues to bleed, a visit to the emergency department might
be appropriate. However, this is not the best response from the nurse at this time.
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.) - ANS-Anticholinergics cause dilatation of pupils and vision may be blurred.
Cause xerostomia or dryness of mouth. Cause urinary hesitancy and retention. Reduce
bowel tone and motility and constipation may occur.
A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL
over 8 hours. Which action does the nurse take? ANS: The patient drank 500 milliliters of
bladder irrigation fluid over eight hours. The urine output for this time frame is 100 mL (12.5
mL/hr). Normal urine output is at least 30 mL/hr; therefore, the nurse notifies the health care
provider
A client recovering from total hip replacement surgery reports increased pain with
movement. Which nursing diagnosis is the most appropriate for this client? - ANS-Pain is a
priority problem for a client recovering from total hip replacement surgery
A client relieves severe abdominal pain that radiates to the back by sitting forward with the
knees bent. Which laboratory test will the nurse expect to be prescribed for this client? -
ANS-Serum amylase. Amylase is a digestive enzyme secreted by the pancreas. Since the
client is demonstrating signs of acute pancreatitis, the nurse should expect a serum amylase
level to be prescribed
A client reports having chest irradiation as a child for non-Hodgkin lymphoma (NHL). On
which potential adulthood complication will the nurse focus when assessing this client? -
ANS-The development of secondary cancers in adults is a long-term complication of
childhood cancer treatment. These cancers can be site specific, such as lung cancer or
leukemia.
A client takes a statin as prescribed. Which action does the nurse implement to identify if
the client is experiencing any side effects of the medication? - ANS-Assess for muscle
tenderness.
Myalgia or muscle tenderness may indicate the development of rhabdomyolysis, which is an
adverse reaction to statin medication.
A client who received ascorbic acid for the treatment of scurvy asks the nurse, "How does
ascorbic acid treat my symptoms?" Which response by the nurse is appropriate? - ANS-"It
is responsible for collagen synthesis."
Ascorbic acid (vitamin C) is responsible for collagen synthesis and helps prevent scurvy
(joint pain, weakness), infant anemia, and oxalate hypersensitivity.
A client with a chronic kidney injury takes sevelamer as prescribed. Which finding indicates
to the nurse that the medication is effective? - ANS-Sevelamer is used to manage
hyperphosphatemia in clients with chronic kidney injury. It binds phosphate in the bowels to
facilitate excretion in the stool. Effective treatment with sevelamer results in a serum
,phosphate value within the normal range of 2.4 to 4.4 mg/dL (0.78 to 1.42 mmol/L).
Effective treatment with sevelamer results in a normal calcium level.
A client with a history of intravenous drug abuse experiences a low-grade fever, cough,
night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum.
Which transmission-based precaution will the nurse use for this client? - ANS-The client's
history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens
(M. tuberculosis). Airborne transmission-based precautions should be initiated immediately.
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? -
ANS-Individuals in this generation have a tendency to want work-life balance
A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse
take when performing cardiopulmonary resuscitation (CPR)? - ANS-Use the heel of one
hand for sternal compressions.
After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and
toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? -
ANS-Hypocalcemia.
Hypocalcemia results from blood transfusions containing citrate. Citrate causes increased
cell membrane permeability, leading to increased neuromuscular excitability, which may
result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm,
seizures, and cardiac arrest may occur.
Hypercalcemia causes decreased neuromuscular excitability. Signs of this imbalance
include fatigue, hypoactive deep tendon reflexes, decreased muscle tone and strength, bone
pain, and decreased gastrointestinal motility
An adolescent client is brought to the hospital with a head injury requiring emergency
surgery. The client's parents are out of the country. The client is staying with the paternal
grandparents. The nurse identifies which source as legal consent for surgery? - ANS-The
paternal grandparents.
Any grandparent can give consent for a minor grandchild in an emergency, if the parents
are not present.
If no family members are available and the client's condition is life-threatening, the surgeon
can perform surgery with assumed consent.
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? - ANS-An unemancipated minor may sign the
consent for medical treatment for the client's own custodial child.
During an assessment the nurse suspects that an injured child is a victim of physical abuse.
Which action is the nurse's primary legal responsibility in this situation? - ANS-Nurses are
obligated to report suspected child abuse to local authorities.
he nurse observes a nursing assistive personnel (NAP) prepare to provide mouth care to a
client who is comatose. Which action made by the NAP requires the nurse to intervene? -
ANS-The NAP raises the head of the bed thirty degrees.
The client who is comatose is placed in a side-lying position with the bed flat. In this
position, saliva automatically runs out of the mouth by gravity instead of being aspirated into
the lungs
The charge nurse reviews the medical records of several clients. Which documentation
from a staff nurse requires the charge nurse to follow-up? - ANS-The nurse should not
document that an occurrence report or incident report was completed. This documentation
requires follow-up.
, The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate
for the nurse to implement? (Select all that apply.) - ANS-Teach family members about
physical signs of impending death.
Encourage the management of adverse signs and symptoms.
Assess family coping mechanisms to handle impending loss.
The health care provider prescribes a unit of packed red blood cells for a client admitted
with lower gastrointestinal bleeding. Which step will the nurse take when administering the
blood product? (Select all that apply.) - ANS-Ensure adequate infusion access is present
before obtaining the blood from the blood bank.
The infusion should be started within 30 minutes of removing the blood from the blood bank
refrigerator.
Two-person verification in the presence of the client is done to make sure that the blood
product matches the health care provider's prescription and the blood product is properly
identified to the client to prevent a blood incompatibility error.
The client should be closely monitored for the first 15 to 30 minutes of the transfusion.
The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial
growth.
The health care provider prescribes an external urinary catheter for a client with urinary
incontinence. Which action does the nurse take after the catheter is rolled onto the penis? -
ANS-Ensure there is 1 to 2 inches of space at the end of the catheter.
The magnetic resonance imaging report for a comatose client with a traumatic brain injury
(TBI) states that forces disrupted the structure of neurons and nearby blood vessels. Which
type of TBI will the nurse suspect this client experienced? - ANS-In a diffuse axonal injury,
axons in the cerebral hemispheres, corpus callosum, and brain stem are damaged. This
typically results from high-speed acceleration, deceleration, or a rotational injury from a
motor vehicle crash. Bleeding may or may not be present, but global cerebral edema is
present.
The newly-licensed nurse states to the nurse preceptor, "I am so frustrated. I take so long
to pass medications, and I make administration errors nearly every day. Because I am so
slow, I have to stop to get my other tasks done. " Which advice by the preceptor best
addresses the nurse's concerns? - ANS-"Interruptions can cause errors, so let's talk about
how to stay focused."
The wrong patient receives carisoprodol from the nurse. Which strategy should the nurse
use to reduce the risk of malpractice litigation? (Select all that apply.) - ANS-2) CORRECT
— The health care provider must be notified of any medication error so that corrective action
or monitoring can be instituted immediately.
3) CORRECT — The manager will follow up with the client immediately to explain the
incident and to monitor for additional needs
The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp,
face, and trunk. Which transmission-based precaution does the nurse implement for this
child? - ANS-The client demonstrates signs of a varicella infection. Airborne and contact
precautions are needed and should be maintained for at least 5 days after the onset of the
rash and until the vesicular lesions are gone
The nurse admits several clients during the day shift. ANS: Place the client who is returning
from a total knee replacement in the same room as the client who has been diagnosed with
pancreatitis. This is the best room assignment for the nurse to make. Neither client is
infected. Pancreatitis is an inflammatory process of the pancreas and not an infectious
disease.
A client diagnosed with thrombocytopenia calls the clinic nurse. The client states, "I just cut
my skin while shaving; the bleeding won't stop even though I placed a bandage over the
cut." Which response by the nurse is best? - ANS-If the client holds pressure for a
significant amount of time but continues to bleed, a visit to the emergency department might
be appropriate. However, this is not the best response from the nurse at this time.
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.) - ANS-Anticholinergics cause dilatation of pupils and vision may be blurred.
Cause xerostomia or dryness of mouth. Cause urinary hesitancy and retention. Reduce
bowel tone and motility and constipation may occur.
A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL
over 8 hours. Which action does the nurse take? ANS: The patient drank 500 milliliters of
bladder irrigation fluid over eight hours. The urine output for this time frame is 100 mL (12.5
mL/hr). Normal urine output is at least 30 mL/hr; therefore, the nurse notifies the health care
provider
A client recovering from total hip replacement surgery reports increased pain with
movement. Which nursing diagnosis is the most appropriate for this client? - ANS-Pain is a
priority problem for a client recovering from total hip replacement surgery
A client relieves severe abdominal pain that radiates to the back by sitting forward with the
knees bent. Which laboratory test will the nurse expect to be prescribed for this client? -
ANS-Serum amylase. Amylase is a digestive enzyme secreted by the pancreas. Since the
client is demonstrating signs of acute pancreatitis, the nurse should expect a serum amylase
level to be prescribed
A client reports having chest irradiation as a child for non-Hodgkin lymphoma (NHL). On
which potential adulthood complication will the nurse focus when assessing this client? -
ANS-The development of secondary cancers in adults is a long-term complication of
childhood cancer treatment. These cancers can be site specific, such as lung cancer or
leukemia.
A client takes a statin as prescribed. Which action does the nurse implement to identify if
the client is experiencing any side effects of the medication? - ANS-Assess for muscle
tenderness.
Myalgia or muscle tenderness may indicate the development of rhabdomyolysis, which is an
adverse reaction to statin medication.
A client who received ascorbic acid for the treatment of scurvy asks the nurse, "How does
ascorbic acid treat my symptoms?" Which response by the nurse is appropriate? - ANS-"It
is responsible for collagen synthesis."
Ascorbic acid (vitamin C) is responsible for collagen synthesis and helps prevent scurvy
(joint pain, weakness), infant anemia, and oxalate hypersensitivity.
A client with a chronic kidney injury takes sevelamer as prescribed. Which finding indicates
to the nurse that the medication is effective? - ANS-Sevelamer is used to manage
hyperphosphatemia in clients with chronic kidney injury. It binds phosphate in the bowels to
facilitate excretion in the stool. Effective treatment with sevelamer results in a serum
,phosphate value within the normal range of 2.4 to 4.4 mg/dL (0.78 to 1.42 mmol/L).
Effective treatment with sevelamer results in a normal calcium level.
A client with a history of intravenous drug abuse experiences a low-grade fever, cough,
night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum.
Which transmission-based precaution will the nurse use for this client? - ANS-The client's
history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens
(M. tuberculosis). Airborne transmission-based precautions should be initiated immediately.
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? -
ANS-Individuals in this generation have a tendency to want work-life balance
A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse
take when performing cardiopulmonary resuscitation (CPR)? - ANS-Use the heel of one
hand for sternal compressions.
After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and
toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? -
ANS-Hypocalcemia.
Hypocalcemia results from blood transfusions containing citrate. Citrate causes increased
cell membrane permeability, leading to increased neuromuscular excitability, which may
result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm,
seizures, and cardiac arrest may occur.
Hypercalcemia causes decreased neuromuscular excitability. Signs of this imbalance
include fatigue, hypoactive deep tendon reflexes, decreased muscle tone and strength, bone
pain, and decreased gastrointestinal motility
An adolescent client is brought to the hospital with a head injury requiring emergency
surgery. The client's parents are out of the country. The client is staying with the paternal
grandparents. The nurse identifies which source as legal consent for surgery? - ANS-The
paternal grandparents.
Any grandparent can give consent for a minor grandchild in an emergency, if the parents
are not present.
If no family members are available and the client's condition is life-threatening, the surgeon
can perform surgery with assumed consent.
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? - ANS-An unemancipated minor may sign the
consent for medical treatment for the client's own custodial child.
During an assessment the nurse suspects that an injured child is a victim of physical abuse.
Which action is the nurse's primary legal responsibility in this situation? - ANS-Nurses are
obligated to report suspected child abuse to local authorities.
he nurse observes a nursing assistive personnel (NAP) prepare to provide mouth care to a
client who is comatose. Which action made by the NAP requires the nurse to intervene? -
ANS-The NAP raises the head of the bed thirty degrees.
The client who is comatose is placed in a side-lying position with the bed flat. In this
position, saliva automatically runs out of the mouth by gravity instead of being aspirated into
the lungs
The charge nurse reviews the medical records of several clients. Which documentation
from a staff nurse requires the charge nurse to follow-up? - ANS-The nurse should not
document that an occurrence report or incident report was completed. This documentation
requires follow-up.
, The family sits at the bedside of a client nearing the end-of-life. Which action is appropriate
for the nurse to implement? (Select all that apply.) - ANS-Teach family members about
physical signs of impending death.
Encourage the management of adverse signs and symptoms.
Assess family coping mechanisms to handle impending loss.
The health care provider prescribes a unit of packed red blood cells for a client admitted
with lower gastrointestinal bleeding. Which step will the nurse take when administering the
blood product? (Select all that apply.) - ANS-Ensure adequate infusion access is present
before obtaining the blood from the blood bank.
The infusion should be started within 30 minutes of removing the blood from the blood bank
refrigerator.
Two-person verification in the presence of the client is done to make sure that the blood
product matches the health care provider's prescription and the blood product is properly
identified to the client to prevent a blood incompatibility error.
The client should be closely monitored for the first 15 to 30 minutes of the transfusion.
The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial
growth.
The health care provider prescribes an external urinary catheter for a client with urinary
incontinence. Which action does the nurse take after the catheter is rolled onto the penis? -
ANS-Ensure there is 1 to 2 inches of space at the end of the catheter.
The magnetic resonance imaging report for a comatose client with a traumatic brain injury
(TBI) states that forces disrupted the structure of neurons and nearby blood vessels. Which
type of TBI will the nurse suspect this client experienced? - ANS-In a diffuse axonal injury,
axons in the cerebral hemispheres, corpus callosum, and brain stem are damaged. This
typically results from high-speed acceleration, deceleration, or a rotational injury from a
motor vehicle crash. Bleeding may or may not be present, but global cerebral edema is
present.
The newly-licensed nurse states to the nurse preceptor, "I am so frustrated. I take so long
to pass medications, and I make administration errors nearly every day. Because I am so
slow, I have to stop to get my other tasks done. " Which advice by the preceptor best
addresses the nurse's concerns? - ANS-"Interruptions can cause errors, so let's talk about
how to stay focused."
The wrong patient receives carisoprodol from the nurse. Which strategy should the nurse
use to reduce the risk of malpractice litigation? (Select all that apply.) - ANS-2) CORRECT
— The health care provider must be notified of any medication error so that corrective action
or monitoring can be instituted immediately.
3) CORRECT — The manager will follow up with the client immediately to explain the
incident and to monitor for additional needs
The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp,
face, and trunk. Which transmission-based precaution does the nurse implement for this
child? - ANS-The client demonstrates signs of a varicella infection. Airborne and contact
precautions are needed and should be maintained for at least 5 days after the onset of the
rash and until the vesicular lesions are gone
The nurse admits several clients during the day shift. ANS: Place the client who is returning
from a total knee replacement in the same room as the client who has been diagnosed with
pancreatitis. This is the best room assignment for the nurse to make. Neither client is
infected. Pancreatitis is an inflammatory process of the pancreas and not an infectious
disease.
