Cat 1-Hesi Exit Exam with 100% Correct Answers 2022-23

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 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct answer-A cervical laceration In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? - Correct 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? - Correct answerSet 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 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct answer-External manifestation of a spinal abnormality What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP)? - Correct answer-Evaluate the experience of the UAP A female resident of a long-term care facility is being admitted to the medical department. The client has a fractured hip and has methicillin-resistant staphylococcus aureus (MRSA). Which room should the charge nurse assign this client? - Correct answer-A semi-private room with a client who also has methicillinresistant staphylococcus aureus (MRSA) The nurse is preparing a client for surgery. Which finding indicates that the client is ready to proceed to the operating room (OR) for a scheduled surgical procedure? - Correct answer-Hemoglobin 10.1 grams The nurse is preparing to administer an intramuscular injection in the ventrogluteal site of a client who weighs 80 kg. What size needle should the nurse select? - Correct answer-21-gauge, 1.5-inch needle A client at 38-weeks gestation is in active labor, and a vaginal birth after Cesarean section (VBAC) is planned. Vaginal exam indicates that the client is 6 cm dilated, 90% effaced, and at station 0 with intact membranes. As the client's contraction become stronger, the fetal heart rate decelerates during the contractions but returns to baseline. What action should the nurse take? - Correct answer-Continue to monitor the client's labor progress An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the risk for urinary incontinence, what action should the nurse implement? - Correct answer-Keep the call bell within the client's reach Which diagnostic tests are most important for the nurse to monitor when providing care for a client with a bowel obstruction? - Correct answer-Serum electrolytes 28. A 72-year-old male client reports that he has felt depressed since his wife died six months ago. What question is most important for the nurse to ask this client? - Correct answer-"Have you ever felt like hurting yourself?" After administering the first dose of newly prescribed to four clients within a thirty minute time frame, the nurse evaluates each client for therapeutic responses or any adverse reactions. Which medication should the nurse evaluate first? - Correct answerHYdromorphone (Dilaudid) What is the most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter? - Correct answerShortness of breath The nurse is developing a plan of care for a client who has a prescription for the calcium channel-blocker nifedipine (Procardia) to treat angina pectoris. What is the purpose for administration of this medication? - Correct answer-Decrease myocardial oxygen demands While transcribing a new prescription, the nurse notes that the prescribed dosage is much lower than the recommended dosage listed in the drug reference guide. Which client data supports this dosage reduction? - Correct answer-Increased liver enzymes The nurse notes that a postoperative adult client's respiratory rate is 10 breaths/minute. Which factor in the client's history is the most likely explanation for this finding? - Correct answer-The PCA pump containing morphine sulfate was discontinued 15 minutes before vital signs were taken The charge nurse working on a postpartum unit is making assignments for a staff consisting of a registered nurse (RN), a practical nurse (PN), and two unlicensed assistive personnel (UAP). Which client should the charge nurse assign to the registered nurse? - Correct answer-A primigravida who delivered an infant 6 hours ago via vaginal delivery and is now complaining of seeing spots 35. A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? - Correct answer-Initiate parenteral antibiotic therapy A child with heart is receiving the diuretic furosemide (Lasix) and has a serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? - Correct answer-Heart rate and cardiac rhythm It is determined that a client with breast cancer has metastasis to the liver. What is the most likely explanation for the client's risk of developing hemorrhagic tendencies? - Correct answer-The inability of the liver to synthesize clotting factors The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? - Correct answer-Vital signs Which instruction should the nurse provide a client who is taking the conventional antipsychotic medication chlorpromazine (Thorazine) for schizophrenia? - Correct answer-Immediately report rigidity of the musculoskeletal system or a sudden high fever A client is receiving a continuous infusion of normal saline at 125 ml per hour. The nurse prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the prescription. In which sequence should the nurse implement the procedure? (Arrange with first on top and last on bottom) - Correct answer-1. Spike a new bag of normal saline 1000ml using new tubing 2. Open the clamp on the tubing to bleed all air from the line 3. Close the clamp below the pump and at the client's venous access 4. Place the pump on hold and replace the tubing in the chamber 5. Attach the distal end of the new tubing to the client's venous 6. Open all tubing clamps to the client and start the pump A client who is wheelchair bound demonstrates positive Thomas test after admission to the rehabilitation unit. The healthcare provider prescribes positioning the client prone for 30 minutes three times each day to prevent further flexion contractures. Based on this finding, what change in the client's plan of care should the nurse expect? - Correct answer-There may be a delay in the rehabilitation process Prostaglandin E2 (Prostin E2) is prescribed for client who had a missed spontaneous abortion. Which finding should the nurse expect? An increase in - Correct answerUterine contractions A client with a general anxiety disorder is pacing the hallway. The client tells the nurse,"My heart is just racing and sometimes it feels like it's fluttering. I'm feeling short of breath and dizzy." What action should the nurse implement first? - Correct answerObtain the client's signs 44. A 22-year-old is involved in a motor vehicle collision and the spinal cord is severed at the second cervical spine (C-2). What is the most likely outcome of this injury? - Correct answer-Death at the scene of the accident due to respiratory arrest A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L, but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What