HESI CAT exam studoc Questions and Answers

59 yo male client is brought to the emergency room where he is assessed to have a Glasgow coma scale of 3. based on this assessment, how should the nurse characterize the clients condition? a. client has increase icp b. he has a good prognosis for recovery c. this client is conscious, but is not oriented to time and place d. he is in a coma and has a very poor prognosis - Answer- d. he is in a coma and has a very poor prognosis at a community health fair, 50 yo female tells the nurse that she has an annual physical exam that includes a breast exam and an annual mammogram. how should the nurse respond? a. encourage the woman to explore her fears about breast cancer b. ask the woman if she performs monthly breast self exams c. recommend the women for adhering to the recommend cancer detection guidelines d. advise the woman that mammogram are only needed every two yrs of age - Answer- b. ask the woman if she performs monthly breast self exams which assessment finding should indicate to the nurse that client with arterial hypertension is expericing a cardiac complication? a. complaints of occipaital headache b. palpable dorsal is pedis pulse bilaterally c. complaints of SOB on exertion d. bp of 160/90 - Answer- c. complaints of SOB on exertion a college student who is diagnosed with vaginal infection and vulva irritation describes the vaginal discharge as having cottage cheese appearance. which prescription should the nurse implement first? a. cleanse perineum with warm soapy water 3 times per day b. instill the first dose of nystatin vaginally per applicator c. perform glucose measurement using capillary blood sample d. obtain a blood speciment for sexually transmitted disease - Answer- b. instill the first dose of nystatin vaginally per applicator a client in acute renal failure has serum potassium of 7.5. based on this finding, the nurse should anticapate implementing which action? a. administer IV NS rapidly and NPH subq b. administer a retention enema of kayexalate c. add 40 KCL to present IV solution d. administer lidocaine bolus IV push - Answer- b. administer a retention enema of kayexalate A client who had an intraosseous (IO) cannula placed by the healthcare provider for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse takes first? a. Discontinue the IO infusion b. Administer an analgesic via the IO site c. Elevate the extremity with the IO site d. Notify the healthcare provide - Answer- a. Discontinue the IO infusion The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to male room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? a. A 45-year-old who has a chronic hepatitis B. b. A 35-year-old with lupus erythematous c. A 19-year-old who is diagnosed with rubella d. A 25-year-old with herpes lesions of the vulva - Answer- b. A 35-year-old with lupus erythematous A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? a. Breathe into the spirometer using normal breath volumes b. Exhale forcefully into the tubing for 3 to 5 seconds c. Inspire deeply and slowly over 3 to 5 seconds d. Perform IS breathing exercises every 6 hours - Answer- c. Inspire deeply and slowly over 3 to 5 seconds The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? a. You will be able to cope with your symptoms b. It will help you function better in the community c. The medication will help you think more clearly - Answer- c. The medication will help you think more clearly A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement? a. Offer to obtain a new breakfast tray in an hour so the clie