Hesi Exit 2022 - Cat exam 1 – Questions And Answers

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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- "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? Correct Ans:- A cervical laceration In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- "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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- 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? Correct Ans:- External manifestation of a spinal abnormality