HESI RN CAT EXAM 2023 V1&V2 QUESTIONS& ANSWERS

HESI RN CAT EXAM 2023 V1&V2 QUESTIONS& ANSWERS 1-A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, howshould the nurse characterize the client’s condition? a. The client has increased intracranial pressure b. He has a good prognosis for recovery c. This clientis conscious, but is not oriented to time and place d. He isin a coma, and has a very poor prognosis Correct D 2- At a community health fair, a 50-year-old woman tellsthe nurse that she has anannual physical exam that includes a clinical 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 ifshe also performs monthly breast self- exams. c. Commend the woman for adhering to the recommended cancer detection guidelines. d. Advise the woman that mammograms are only needed every two years ather age. Correct B 3- Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication? a. Complaints of an occipital headache b. A palpable dorsal is pedis pulse bilaterally c. Complaints of shortness of breath on exertion d. A blood pressure of 160/90 Correct C 4- A college student who is diagnosed with a vaginal infection and vulva irritation describesthe vaginal discharge as having a “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 (Mycostatin) vaginally per applicator c. Perform glucose measurement using a capillary blood sample d. Obtain a blood specimen for sexually transmitted disease (STDs)Correct B 5- A client in acute renal failure has serum potassium of 7.5 mEq/L. Based on thisfinding, the nurse should anticipate implementing which action? a. Administer an IV of normal saline rapidly and NPH insulsubcutaneously. b. Administer a retention enema of Kayexalate c. Add 40 mEq of KCL (potassium chloride) to present IV solution. d. Administer a lidocaine bolusIV push. Correct B 6- A client who had an intraosseous (IO) cannula placed by the healthcare providerfor 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 provider Correct A 7- 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 Correct B 8- A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this clientto doto 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 Correct C 9- The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statementshould 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” d. It will improve your grooming and hygiene Correct C 10 – 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 client can take the Zithromax b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating c. Tell the client to skip that day’s dose and resume taking the Zithromax thenext day d. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast Correct B 11- What instruction is most important for the nurse to provide a female client whohas just been diagnosed with trichomoniasis? a. Avoid douching b. Treat sexual partner (s) concurrently c. Avoid using moist washcloths when bathing d. Postpone becoming pregnant until the infection is treated Correct B 12- A primigravida at term comesto the prenatal clinic and tellsthe nurse that she ishaving contractions every 5 min. The nurse monitors the clientfor one hour, using an external fetal monitor, and determines that the client’s contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to30 seconds, with mild intensity by palpation. What action should the nurse take? a. Tell the clientto go directly to the hospital for admission to labor and deliveryfor active labor b. Send the client home and instruct her to call the clinic when her contractionsoccur 5 minutes apart for one hour c. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection Correct B 13- Which instruction should the nurse provide to an elderly client who is taking anACE inhibitor and a calcium channel blocker? a. Wear long-sleeved clothing when outdoors b. Report the onset of sore throat c. Eat plenty of potassium-rich food d. Change the position slowly Correct D 14- Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? a. Place a pulse oximeter on the heel b. Swaddle the infant in a warm blanket c. Record the findings on the flow sheet d. Check the vital signs in 15 minutes Correct C 15- A client admitted to the hospital for depression is escorted to a private room.Prior to leaving the room, what intervention is most important for the nurse to implement? a. Explain the programs guidelines b. Search all personal belongings c. Initiate psychosocial assessment d. Review the healthcare’s provider’s prescription Correct B 16- An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse’s attitude as challenging and offensive. What action is best for the nurse manager to take? a. Have both nurses meetseparately with the staff mental health consultant b. Listen actively to both nurses and offer suggestions to solving dilemma c. Ask the senior nurse to examine mentoring strategies used with the new graduate d. Ask the nurses to meet with the nurse-manager to identify ways of working together Correct D 17- Which nursing diagnosis has the highest priority when planning care for a clientin cardiogenic shock? a. Risk for imbalance body temperature b. Excessfluid volume c. Fatigue d. Ineffective Tissue Perfusion Correct D 18- A client who had a cerebral vascular accident (CVA) Is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client’s current health status? a. Risk for impaired tissue integrity related to impaired physical mobility b. Impaired skin integrity related to altered circulation and pressure c. Ineffective tissue perfusion related to inability to move self in bed. d. Impaired physical mobility related to the leftside paralysis Correct B 19- The nurse offers dietteaching to a female college student who was diagnosedwith iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet? a. Drink whole milk instead of skim milk to enhance the body’s production ofamino acids b. Take vitamin K 10mg PO daily to enhance production of red blood cells c. Increase amounts of dark yellow vegetablessuch as carrots to fortify ironstores d. Combine several legumes and grains such as beans and rice to form complete proteins Correct D 20- The nurse istriaging clientsfrom a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triagetag color should the nurse place on this client? a. Black b. Yellow c. Green d. Red Correct D 21- Which action should the nurse include in the plan of care a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)? a. Initiate cardiac telemetry monitoring b. Maintain continuously pulse oximetry c. Perform capillary glucose measurements d. Monitor serum creatinine levels Correct D 22- A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+pitting edema around the ankles. It is most important for the nurse to obtain what additional client data? a. Bladder distention b. Serum albumin level c. Abdominal girth d. Breath sounds Correct D 23- A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to developa therapeutic relationship with this client, which information is most important for thenurse to determine? a. The family’sreaction to this situation b. The nurse’s feeling about this client c. What losses the client recently experienced d. Why the client attempted to kill himself Correct B 24- Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia? a. A young adult client with intractable vomiting from food poisoning b. A client who developed hyperparathyroidism in late adolescence c. A middle-age male client in renal failure following an unsuccessful kidney transplant d. A female client who is overzealous with her intake of simple carbohydrates Correct C 25- While assessing a client who is experiencing Cheyne-Stokes respirations, thenurse observes periods of apnea. What action should the nurse implement? a. Elevate the head of the client’s head b. Auscultate the client’s breath sound c. Measure the length of the apneic periods d. Suction the client’s oropharynx Correct C 26- The nurse is preparing to administer the 0800 dose of 20 units of Humulin R toan 8- year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first? a. Administer the 20 Units of Humulin R subcutaneously as prescribed b. Ask the girl ifshe will be eating her breakfast this morning c. Discuss changing the insulin prescription to Lispro with the healthcare provider d. Explain to the mother the importance of eating the schedule meals Correct B 27- The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers,which action is most important for the nurse to implement? a. Maintain possession of the evidence collection kit at all times until submittedto law enforcement b. Provide discharge instruction for prophylactic antibiotic, pregnancy, and HIV prevention medication c. Document the characteristics of the various sites of sample collection d. Assist the client with toileting, hygiene, and dressing with clean clothes. Correct A 28- The nurse is caring for a 10-year-old who is diagnosed with acute glomerulonephritis. Which outcome is the priority for this child? a. Activity tolerance as evidenced by performing appropriate age-level-activities b. No signs of skin breakdown as evidenced by intact skin and no redness c. Adequate nutritional status as evidenced by no weight gain or loss d. Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr Correct D 29- A 20-year-old male clientis diagnosed with Ewing’s sarcoma following examination for a knee injury. Which instruction is most important for the nurse toprovide the client? a. Take analgesicsregularly to reduce the pain b. Notify the healthcare provider if the swelling worsens c. Avoid weight-bearing until the injury heals d. Seek treatment for the sarcoma immediately Correct D 30- The nurse in the newborn nursery admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finds helps to confirm this diagnosis? a. Pink lips and tongue with cyanotic hands and feet b. Respiration rate of 40 and heart rate of 144 c. Centralized cyanosis and tachycardia when crying d. Desquamation from areas of cracked, parchment-like skin Correct C 31- A postoperative client returns to the nursing unit following a ureter lithotomy viaa flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client? a. Ineffective airway clearance b. Altered nutrition lessthan body requirements c. Fluid volume excess d. Activity intolerance Correct A 32- A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. what is the maximumdosage in mg that the nurse should administer to this client? (Enter numeric value only) Ans: 2 0.4 mg/dose = x mg/5 doses X= 2 mg 33- A male client admitted three days ago with respiratory failure is intubated andwith 40% oxygen per facemask is initiated. Currently his temperature is 99 F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits.What outcome should the nurse evaluate to measure for successful estuation? a. Exhibits adequate tissue perfusion b. Remainsfree of injury c. Remainsfree of infection d. Maintains effective breathing pattern Correct D