HESI CAT EXAM WITH 100% CORRECT ANSWERS

A client with irritable bowel syndrome is recovering from surgery to create an ileostomy what foods should the nurse instruct the client to avoid to reduce the risk of food blockage - ANSWER-Dried fruits & nuts Rationale: dried fruits and nuts can cause a blockage in the small intestine the client should be instructed to avoid these food items with an ileostomy A client with malnutrition is assessed for osteomalacia what data show the nurse review to determine their clients risk for this health problem - ANSWER-Vitamin D levels Rationale: Malnutrition has widespread affects on various organ systems osteomalacia is defective mineralization of newly formed bones secondary to chronic deficiency of vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide the nurse with the most accurate information regarding this health problem The nurse has determine an adolescent client needs reinforcement education about prevention of a sickle cell crisis which instruction should the nurse include select all that apply - ANSWER-Wear warm clothes outside in cold weather take your hydroxyurea (Droxia) daily as prescribed Drink at least eight 12 ounces glasses of water a day Get regular exercise but do not exercise so much that you become tired Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle cell disease. it occurs when the micro circulation is obstructed by sickling of the red blood cells resulting in local tissue ischemia and severe pain. the three most common identify triggers for the development of a vaso-occlusive crisis are hypoxemia, dehydration, and body temperature changes The nurse is caring for a client with schizophrenia who has refused they are risperidone for the last week the client has been suspicious of nursing staff and periodically aggressive for the past three days today the client broke a chair in their room and is making verbal threats to the nurse and to other clients in the day wrong what is the first action the nurse should take - ANSWER-Remove the other clients in nonessential staff from the day room Rationale: schizophrenia is a mental health disorder which causes hallucinations, delusions, disorder thought process and impaired behavior function. Safety for all staff clients and visitors is priority and potential violence situations A nurse who normally works on a post surgical care unit has been asked to float to the preoperative care unit what is the best response by the nurse - ANSWER-I don't feel totally comfortable floating so I would like to be paired with a resource nurse for my shift Rationale: The nurse has acknowledged their discomfort with floating and has also identified a means of making a float shift nurse more comfortable and important part of a successful float shift and identifying using resources on the float unit including a partnership with a specific resource nurse for the shift to answer questions locate supplies etc. The nurse is preparing to administer medication through a client's nasalgastric tube what will the nurse do first when administering these medications - ANSWER-Assessed for placement of the nasalgastric tube Rationale: Before inserting any medication through the nasal gastric tube the nurse needs to assess for correct placement of the tube A client with an stage renal failure has requested no further treatment be provided when the oldest daughter arrives to visit she is visibly upset that all dialysis treatments have ended in demands that treatment be continue what should the nurse do it this time - ANSWER-Explained that the client has requested that all treatments be stop Rationale: The nurse is responsible for the following clients wishes for treatment the daughter does not need to leave because there's no evidence that the client is upset resuming Dallas treatment is not what the client wants and should not be done the nurse can explain the change in treatments with a daughter and does not need to ask a physician to have this conversation The education department of a healthcare organization has design client education sheet that explains the process of being admitted to the hospital in English Spanish and French since these are the three major language is spoken by the hospitals client population what does the client education sheet reflects - ANSWER-Sensitivity to the diverse Client population Rationale: By creating a client education sheet that can be read by the hospitals major client population the education department is demonstrating sensitivity to the diverse client population the education sheet does not reflect racial profiling stereotyping or inappropriate categorizing of the clients population The nurse is emptying the urinary collection bag for a client with history of HIV in which sequence sure the nurse perform the following actions after the urinary collection bag has been drained - ANSWER-Ensure urinary collection bag is placed below the clients bladder empty that your receptacle remove PPE Wash hands with soap & water Document amount of urine collected Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne illnesses in cases of hematuria healthcare professionals including nurses need to completely situational risk assessment prior to each client interaction to determine risk and choose the appropriate infection control strategy to minimize risk to themselves and their client population according to the CDC A GRANDSon is concern about the older clients happiness and so much time is spent talking about the past what should the nurse respond to the grandson - ANSWERReminiscing is a common activity in older adults that helps them to stay connected Rationale: The nurse should explain that reminiscing is normal and common activity in older adults talking about the past helps older adult clients stay connected to other people by providing a topic of conversation even if they don't experience much during the day Family of an elderly Japanese woman is upset because the client has not received any pain medication the nurse explains that the client never complain about pain and did not write the pain and severe when assess what should the nurse manager do - ANSWERExplain that in the Japanese culture people often show a stoic response to pain so that it is important to look for PHYSICAL clues Rationale: individuals of Japanese descent will not complain about pain as they do not want to dishonor themselves or their families some will either refuse pain medication when offered therefore it is important to look for physical clothes like (rocking, sweat on brows, elevated blood pressure) and input from the family when assessing for pain The nurse assessed audible expiratory wheezes over a clients lower lobes what should the nurse do first after completing this assessment - ANSWER-Raise the Head of the bed to a 60° angle Rationale: The client is demonstrating bilateral lower lobe wheezes the first thing the nurse should do is raise the head of the bed to a 60° angle in order to improve ventilation The nurse is flushing a clients peripheral intravenous catheter saline lock with sterile normal saline during the flush the nurse notes that resistance is met what action should the nurse take - ANSWER-Remove the saline lock and re-insert in another site Rationale: The peripheral in a minute IV catheter device also known as a saline lock is a device flushed with saline and applied to a PICC to maintain IV access and patency. To maintain patency the lock should be flush with 3 mL of NS before and after each medication administered, after blood draw, and every 12 hours with the saline lock has been not been in use. While saline locks reduce the need to insert IV lines, they do have a risk and should be removed 72 hours after insertion to reduce the likelihood of infection Infiltration - ANSWER-The infusion of fluid or medication outside the vein usually caused by poor IV placement skin will appear swollen and cool to the touch Hematoma - ANSWER-When blood from the veins pools into the surrounding tissues this happens when the needle passes through the rain more than once or if pressure is applied when removing the IV air embolism - ANSWER-Extremely rare complication in which air travels through the IV line into the vein and creates an envelope that could travel to the lungs or heart since the amount of air tolerating is dependent on weight children are more at risk of developing this complication phlebitis - ANSWER-Inflammation of the rain caused by irritation solutions medication or the angiocatheter being in place for days superficial thrombophlebitis - ANSWER-Inflammation of a vein just below the surface of the skin caused by formation of a thrombus this may cause pain, tenderness or hardening of the vein these often resolved without intervention elevating the extremity and applying warm compress can relieve symptoms The case manager on an oncology unit is determining which clients might be appropriate to consider for hospice which client will most likely benefit the most from this level of care - recovering from radioactive iodine for thyroid cancer - metastatic liver cancer receiving IV morphine for pain - recovering from lumpectomy for breast cancer with no nodal involvement - chemotherapy for chronic leukemia w/ low WBC - ANSWER-ANS: Client with metastatic liver cancer receiving IV morphine for pain.