Cat exam 1-Hesi Exit

Cat exam 1-Hesi Exit
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 answerA 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
answerAnswer: 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 answerCheck 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
answerReassess 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 answerA cervical laceration In preparing assignments for the shift, which client is
best for the charge nurse to assign to a practical nurse? - correct answerAn 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 answerC. 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 answerEncourage 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 answerSweating 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 answerStage 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 answerReport 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 answerAcute 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 answerImpaired 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 answerHigh 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 answerDetermine 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 answerNotify 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 answerExternal manifestation of a spinal
abnormality What action should the nurse implement first when delegating nursing
activities to an unlicensed assistive personnel (UAP)? - correct answerEvaluate 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 answerA semi-private room with a client who also has methicillin-
resistant 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 answerHemoglobin 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 answer21-
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 answerContinue 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 answerKeep 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 answerSerum 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 answerDecrease 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 answerIncreased 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 answerThe 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 answerA 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 answerInitiate 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
answerHeart 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 answerThe 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 answerVital signs

, Which instruction should the nurse provide a client who is taking the conventional
antipsychotic medication chlorpromazine (Thorazine) for schizophrenia? - correct
answerImmediately 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 answer1. 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 answerThere 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 answerDeath 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 action should the nurse take? - correct answerDisregard the
advice of the charge nurse and contact the healthcare provider immediately to report
the laboratory value The nurse should carefully assess the client with which urinary
problem for fluid volume deficit? - correct answerPolyuria What nursing intervention
should the nurse include in the plan of care for a client following a bone marrow
aspiration? - correct answerUse of a compression dressing for firm pressure to the site
An outcome for treatment of peripheral vascular disease is, "The client will have
decreased venous congestion". What client behavior would indicate to the nurse that
this outcome has been met? - correct answerAvoids prolonged sitting or standing When
assessing a client, the nurse notices a pulsation below the umbilicus. Upon auscultation
of the area, a "swishing" sound is detected. Based on these findings, what additional
assessment should the nurse perform? - correct answerMeasure the blood pressure An
alert and oriented client requiring droplet precautions is placed in a private room at the
end of the hallway. Several days later, the nurse finds that the client is restless and