Cat exam 1-Hesi Exit
QUESTIONS AND DETAILED
ANSWERS | 100% VERIFIED
CORRECT | GRADE A+
A client is comatose upon arrival to the emergency department after falling a roof.
The client flexes with painful stimuli, and the nurse determines the client's
Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to
implement to maintain the client's airway? - ANSWER-A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50 ml/hr. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need? - ANSWER-ANSWER: 200
25 ml x 8hrs = 200
The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen
saturation rate is indicated at 85%. What action should the nurse take first? -
ANSWER-Check the probe position
A client is known to have an irregular respiratory rate with periods of apnea
lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30-
,second interval followed by an apneic period. What intervention should the nurse
implement? - ANSWER-Reassess the respiratory rate, counting for one full minute
A retiree with depression complains of feeling "lonely and having no purpose" in
life.Based on Erikson's developmental theory, which questions suggest that the
nurse understands the client's most important emotional need? - ANSWER-"What
about your life makes you proud?"
Following a precipitous labor, a client has a continuous trickling of bright red blood
from her vagina. Her uterus is firm and her vital signs are within normal limits. The
nurse determines that the client's symptoms may indicate which condition? -
ANSWER-A cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to
assign to a practical nurse? - ANSWER-An elderly client with Alzheimer's disease
complicated by dysphagia
The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which
action has the highest priority when the nurse implements this prescription? -
ANSWER-Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an
injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should
the nurse-manager who is supervising this nurse take first? - ANSWER-C. Instruct
the nurse to select another injection site
,10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis,
the nurse provides home care instructions to the mother. Which statement by the
child's mother indicates that she understands home care treatment to promote
pulmonary function? - ANSWER-"Chest physiotherapy should be performed at
least twice a day"
The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation? -
ANSWER-Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with Type
1 diabetes mellitus. The parents correctly understands signs of hypoglycemia if
they include which symptom? - ANSWER-Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an
immobile client. What documentation of this finding is best for the nurse to enter
into the client's record? - ANSWER-Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on
her back and upper arms. The child's aunt tells the nurse that the child's parents
abuse drugs and alcohol. What intervention is most essential for the nurse to
implement? - ANSWER-Report assessment findings to the proper legal authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus.
He was diagnosed with a seizure disorder in childhood. What is the most likely
cause of his present condition? - ANSWER-Acute withdrawal from anticonvulsant
medication
, A Chinese-American client who just delivered a baby states that she will not be
able to take the prescribed sitz baths to help heal her episiotomy incision because
this will cause an unhealthy balance of cold and hot forces. When planning
nursing care, what nursing diagnosis has the highest priority? - ANSWER-Impaired
tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In
planning care for this child, which nursing diagnosis has the highest priority? -
ANSWER-High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital herpes
with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is
experiencing an episode of genital herpes. Which nursing intervention has the
highest priority? - ANSWER-Determine if the client has taken acyclovir (Zovirax) for
this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription for
paroxetine (Paxil). The client reports current use of the MAO inhibitor
isocarboxazid
(Marplan). What intervention is most important for the nurse to implement? -
ANSWER-Notify the healthcare provider that the client is currently taking Marplan
While performing a skin inspection on a newborn, the nurse finds a small dimple
and a dark tuft of hair in the lumbosacral area of the infant's back. What is the
most likely indication of this finding? - ANSWER-External manifestation of a spinal
abnormality
QUESTIONS AND DETAILED
ANSWERS | 100% VERIFIED
CORRECT | GRADE A+
A client is comatose upon arrival to the emergency department after falling a roof.
The client flexes with painful stimuli, and the nurse determines the client's
Glasgow Coma Scale (GCS) is 6. Which intervention should the nurse prepare to
implement to maintain the client's airway? - ANSWER-A nasopharyngeal tube
A client is receiving a continuous half strength tube feeding at 50 ml/hr. To
prepare enough of the solution for eight hours, how many ml of full strength
feeding will the nurse need? - ANSWER-ANSWER: 200
25 ml x 8hrs = 200
The alarm of a client's pulse oximeter sounds and the nurse notes that the oxygen
saturation rate is indicated at 85%. What action should the nurse take first? -
ANSWER-Check the probe position
A client is known to have an irregular respiratory rate with periods of apnea
lasting 10 to 15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30-
,second interval followed by an apneic period. What intervention should the nurse
implement? - ANSWER-Reassess the respiratory rate, counting for one full minute
A retiree with depression complains of feeling "lonely and having no purpose" in
life.Based on Erikson's developmental theory, which questions suggest that the
nurse understands the client's most important emotional need? - ANSWER-"What
about your life makes you proud?"
Following a precipitous labor, a client has a continuous trickling of bright red blood
from her vagina. Her uterus is firm and her vital signs are within normal limits. The
nurse determines that the client's symptoms may indicate which condition? -
ANSWER-A cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to
assign to a practical nurse? - ANSWER-An elderly client with Alzheimer's disease
complicated by dysphagia
The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which
action has the highest priority when the nurse implements this prescription? -
ANSWER-Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an
injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should
the nurse-manager who is supervising this nurse take first? - ANSWER-C. Instruct
the nurse to select another injection site
,10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis,
the nurse provides home care instructions to the mother. Which statement by the
child's mother indicates that she understands home care treatment to promote
pulmonary function? - ANSWER-"Chest physiotherapy should be performed at
least twice a day"
The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation? -
ANSWER-Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with Type
1 diabetes mellitus. The parents correctly understands signs of hypoglycemia if
they include which symptom? - ANSWER-Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an
immobile client. What documentation of this finding is best for the nurse to enter
into the client's record? - ANSWER-Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on
her back and upper arms. The child's aunt tells the nurse that the child's parents
abuse drugs and alcohol. What intervention is most essential for the nurse to
implement? - ANSWER-Report assessment findings to the proper legal authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus.
He was diagnosed with a seizure disorder in childhood. What is the most likely
cause of his present condition? - ANSWER-Acute withdrawal from anticonvulsant
medication
, A Chinese-American client who just delivered a baby states that she will not be
able to take the prescribed sitz baths to help heal her episiotomy incision because
this will cause an unhealthy balance of cold and hot forces. When planning
nursing care, what nursing diagnosis has the highest priority? - ANSWER-Impaired
tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In
planning care for this child, which nursing diagnosis has the highest priority? -
ANSWER-High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital herpes
with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is
experiencing an episode of genital herpes. Which nursing intervention has the
highest priority? - ANSWER-Determine if the client has taken acyclovir (Zovirax) for
this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription for
paroxetine (Paxil). The client reports current use of the MAO inhibitor
isocarboxazid
(Marplan). What intervention is most important for the nurse to implement? -
ANSWER-Notify the healthcare provider that the client is currently taking Marplan
While performing a skin inspection on a newborn, the nurse finds a small dimple
and a dark tuft of hair in the lumbosacral area of the infant's back. What is the
most likely indication of this finding? - ANSWER-External manifestation of a spinal
abnormality
