Cat exam 1-Hesi Exit (2026/2027) – Computerized Adaptive Testing
Comprehensive Nursing Assessment | Complete Questions with Correct Answers |
NCLEX-RN® Predictor Preparation| Graded A+|| PASS!!
The nurse assess the perineum of a client who is complaining of perineal pain 6 hours
after a normal delivery, and finds that the client has small perineal (vulvar) hematomas.
Based on this assessment finding, which treatment should the nurse implement? -
answer-Apply cold packs to the perineum
Family members of a client who is in hospice care discuss with the nurse their fears that
their loved one's death will be painful. Which intervention should the nurse implement? -
answer-Provide teaching about available pain control options that might be helpful
Which nurse's behavior is a breach of client confidentiality according to the Health
Insurance Portable Accountability Act (HIPAA) regulations? -answer-Takes home a
daily report sheet with the information of the team's client's
The nurse is assessing a client following hemodialysis. What finding indicates that an
expected outcome of dialysis was achieved? -answer-Decrease in BP
61. The nurse is performing a routine well-child exam on a 5-year-old. While palpating
the lymph nodes, the nurse feels several 0.5 cm nodes in the cervical area that are
round, mobile, non-tender, and non-warm to the touch. What do these findings most
likely represent? -answer-An expected finding for a well child of this age
A client with acute renal failure has many complications. The nurse recognizes what
finding as a sign of an immediate life-threatening situation? -answer-An increased
serum potassium concentration
The nurse completes the Leopold maneuvers for a primipara who is admitted in active
labor and determines that the fetus in the right sacral anterior (RSA) position. On which
quadrants should the nurse place the external fetal heart transducer? (Click the
,chosen location. To change, click on the new location) -answer-Answer: Right-up
quadrant
The practical nurse (PN) reports the patterns of urinary frequency and volume for
several clients. Which finding necessitates further assessment by the RN? -answer-
Voiding 50 ml cloudy urine every hour
Before administering diltiazem (Cardizem SR) the nurse notes that the client's blood
pressure is 140/94. What action should the nurse take? -answer-Administer the
scheduled dose of diltiazem and monitor the client's blood pressure
A male client sitting in his room tells the nurse "The CIA put this transistor right here
under my left ear. They are transmitting messages. Can't you hear them? They're so
loud they scare me." Which response is best for the nurse to provide? -answer-"What is
the message telling you"
The nurse is preparing a discharge plan for an older client who was recently diagnosed
with Alzheimer's disease. Which intervention should the nurse suggest to the spouse if
the client becomes uncooperative at home? -answer-Ensure a calm and predictable
environment
A client in the third trimester of pregnancy reports that she feels some "lumpy places"in
her breasts and that her nipples sometime leak a yellowish fluid. She has an
appointment with her healthcare provider in two weeks. What action should the nurse
take? -answer-Explain that this normal, but can be assessed further at the next
prenatal visit
69. The nurse should instruct the parents of a 2-year-old toddler with Tetralogy of Fallot
to immediately contact their healthcare provider if their child exhibits which symptom? -
answer-Becomes pale and lethargic
A client with end stage renal disease (ESRD) is undergoing peritoneal dialysis.
Whatobservation made by the nurse during the peritoneal dialysis treatment warrants
immediate intervention? -answer-A 2,000 ml amount of dialysate was instilled, and
1,500 ml was drained
A hospitalized male veteran of a foreign war refuses care from a Middle-Eastern
nurse.The client tells the nurse, "I want an American to take care of me!" Which action
should the charge nurse take? -answer-Reassign the client's care to another nurse
The community health nurse is attempting to address the issue of child abuse in a large
metropolitan area. A primary prevention program for child abuse might include which
program? -answer-High school child development and parenting classes
A client's right to give informed consent is based on which ethical principle? -answer-
Autonomy
, A client who suffered a stroke and is now on a ventilator receives nutritional
supplements by the feedings three times a day. The nurse checks the client for a
residual volume before administering the next feeding. Which statement best describes
the rationale for this nursing intervention? -answer-Retention of feeding in the stomach
increases the likelihood of regurgitation and aspiration
A client has a history of chronic atrial fibrillation. Which instruction should the nurse
include in the teaching plan for this client? -answer-Be sure to take the prescribed daily
aspirin
A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse
do first? -answer-Prepare for synchronized cardioversion
It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volume-
control device, when initiating IV therapy for a client following which surgical procedure?
-answer-Craniotomy
Which strategy is most important for the nurse to use when assisting a client with
myasthenia gravis to devise a daily routine? -answer-Perform necessary physically
demanding tasks in the morning
The nursing diagnosis, "Altered nutrition: less than body requirements," is included in
the plan of care for a client with hyperthyroidism. What primary etiology should the
nurse identify when planning care for this client? -answer-Increased metabolic needs
The nurse is triaging victims of a tornado that hit a housing area outside of town.Which
client would the nurse issue a black disaster tag to? -answer-D. A 59-year-old female
with head injury whose pupils are fixed and dilated
A male infant born at 30-weeks gestation at an outlying hospital is being prepared for
transport to a level IV neonatal facility. His respirations are 90/min, and his heart rate is
150beats per minute. Which drug is the transport team most likely to administer to this
infant? -answer-Beractant (Survanta) 100 mg/kg per endotracheal tube
82. A 60-year-old female client takes NPH insulin each morning. What would
necessitate holding this client's usual morning NPH insulin dose? -answer-The client is
NPO for surgical debridement of a leg ulcer at 11:00 a.m
Two weeks following a fracture, a male client is told by the healthcare provider that a
callus has formed at the fracture site. The client expresses concern to the nurse about
the significance of this information. How should the nurse respond? -answer-Offer
reassurance that the healing process is progressing
A 25-year-old female client, a dancer, has just had an ileostomy as a result of Crohn's
disease. In evaluating the client's response to this life change, which behavior would
Comprehensive Nursing Assessment | Complete Questions with Correct Answers |
NCLEX-RN® Predictor Preparation| Graded A+|| PASS!!
The nurse assess the perineum of a client who is complaining of perineal pain 6 hours
after a normal delivery, and finds that the client has small perineal (vulvar) hematomas.
Based on this assessment finding, which treatment should the nurse implement? -
answer-Apply cold packs to the perineum
Family members of a client who is in hospice care discuss with the nurse their fears that
their loved one's death will be painful. Which intervention should the nurse implement? -
answer-Provide teaching about available pain control options that might be helpful
Which nurse's behavior is a breach of client confidentiality according to the Health
Insurance Portable Accountability Act (HIPAA) regulations? -answer-Takes home a
daily report sheet with the information of the team's client's
The nurse is assessing a client following hemodialysis. What finding indicates that an
expected outcome of dialysis was achieved? -answer-Decrease in BP
61. The nurse is performing a routine well-child exam on a 5-year-old. While palpating
the lymph nodes, the nurse feels several 0.5 cm nodes in the cervical area that are
round, mobile, non-tender, and non-warm to the touch. What do these findings most
likely represent? -answer-An expected finding for a well child of this age
A client with acute renal failure has many complications. The nurse recognizes what
finding as a sign of an immediate life-threatening situation? -answer-An increased
serum potassium concentration
The nurse completes the Leopold maneuvers for a primipara who is admitted in active
labor and determines that the fetus in the right sacral anterior (RSA) position. On which
quadrants should the nurse place the external fetal heart transducer? (Click the
,chosen location. To change, click on the new location) -answer-Answer: Right-up
quadrant
The practical nurse (PN) reports the patterns of urinary frequency and volume for
several clients. Which finding necessitates further assessment by the RN? -answer-
Voiding 50 ml cloudy urine every hour
Before administering diltiazem (Cardizem SR) the nurse notes that the client's blood
pressure is 140/94. What action should the nurse take? -answer-Administer the
scheduled dose of diltiazem and monitor the client's blood pressure
A male client sitting in his room tells the nurse "The CIA put this transistor right here
under my left ear. They are transmitting messages. Can't you hear them? They're so
loud they scare me." Which response is best for the nurse to provide? -answer-"What is
the message telling you"
The nurse is preparing a discharge plan for an older client who was recently diagnosed
with Alzheimer's disease. Which intervention should the nurse suggest to the spouse if
the client becomes uncooperative at home? -answer-Ensure a calm and predictable
environment
A client in the third trimester of pregnancy reports that she feels some "lumpy places"in
her breasts and that her nipples sometime leak a yellowish fluid. She has an
appointment with her healthcare provider in two weeks. What action should the nurse
take? -answer-Explain that this normal, but can be assessed further at the next
prenatal visit
69. The nurse should instruct the parents of a 2-year-old toddler with Tetralogy of Fallot
to immediately contact their healthcare provider if their child exhibits which symptom? -
answer-Becomes pale and lethargic
A client with end stage renal disease (ESRD) is undergoing peritoneal dialysis.
Whatobservation made by the nurse during the peritoneal dialysis treatment warrants
immediate intervention? -answer-A 2,000 ml amount of dialysate was instilled, and
1,500 ml was drained
A hospitalized male veteran of a foreign war refuses care from a Middle-Eastern
nurse.The client tells the nurse, "I want an American to take care of me!" Which action
should the charge nurse take? -answer-Reassign the client's care to another nurse
The community health nurse is attempting to address the issue of child abuse in a large
metropolitan area. A primary prevention program for child abuse might include which
program? -answer-High school child development and parenting classes
A client's right to give informed consent is based on which ethical principle? -answer-
Autonomy
, A client who suffered a stroke and is now on a ventilator receives nutritional
supplements by the feedings three times a day. The nurse checks the client for a
residual volume before administering the next feeding. Which statement best describes
the rationale for this nursing intervention? -answer-Retention of feeding in the stomach
increases the likelihood of regurgitation and aspiration
A client has a history of chronic atrial fibrillation. Which instruction should the nurse
include in the teaching plan for this client? -answer-Be sure to take the prescribed daily
aspirin
A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse
do first? -answer-Prepare for synchronized cardioversion
It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volume-
control device, when initiating IV therapy for a client following which surgical procedure?
-answer-Craniotomy
Which strategy is most important for the nurse to use when assisting a client with
myasthenia gravis to devise a daily routine? -answer-Perform necessary physically
demanding tasks in the morning
The nursing diagnosis, "Altered nutrition: less than body requirements," is included in
the plan of care for a client with hyperthyroidism. What primary etiology should the
nurse identify when planning care for this client? -answer-Increased metabolic needs
The nurse is triaging victims of a tornado that hit a housing area outside of town.Which
client would the nurse issue a black disaster tag to? -answer-D. A 59-year-old female
with head injury whose pupils are fixed and dilated
A male infant born at 30-weeks gestation at an outlying hospital is being prepared for
transport to a level IV neonatal facility. His respirations are 90/min, and his heart rate is
150beats per minute. Which drug is the transport team most likely to administer to this
infant? -answer-Beractant (Survanta) 100 mg/kg per endotracheal tube
82. A 60-year-old female client takes NPH insulin each morning. What would
necessitate holding this client's usual morning NPH insulin dose? -answer-The client is
NPO for surgical debridement of a leg ulcer at 11:00 a.m
Two weeks following a fracture, a male client is told by the healthcare provider that a
callus has formed at the fracture site. The client expresses concern to the nurse about
the significance of this information. How should the nurse respond? -answer-Offer
reassurance that the healing process is progressing
A 25-year-old female client, a dancer, has just had an ileostomy as a result of Crohn's
disease. In evaluating the client's response to this life change, which behavior would
