HESI CAT exam studoc/154
Questions with Complete
Solutions/ Verified
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 - -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 - -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 - -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 - -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 - -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 - -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 - -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 - -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 - -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 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 the next
day
d. Provide a PRN dose of an antacid to take with the Zithromax right
after
breakfast - -b. Instruct the client to eat his breakfast and take the
Zithromax two hours after
eating
-What instruction is most important for the nurse to provide a female
client who has
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 - -b. Treat
sexual partner (s) concurrently
-A primigravida at term comes to the prenatal clinic and tells the nurse
that she is having
contractions every 5 min. The nurse monitors the client for 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 to 30 seconds, with
mild intensity by
palpation. What action should the nurse take?
a. Tell the client to go directly to the hospital for admission to labor and
delivery for
active labor
b. Send the client home and instruct her to call the clinic when her
contractions occur
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 - -b. Send the client home and instruct
her to call the clinic when her contractions occur
, -Which instruction should the nurse provide to an elderly client who is
taking an ACE
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 - -d. Change the position slowly
-Assessment finding of a 3-hour-old newborn include: axillary
temperature of 97.7F, 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 - -c. Record the findings on the
flow sheet
-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 - -b. Search all
personal belongings
-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 meet separately 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 - -d. Ask the nurses to meet with the nurse-manager to identify
ways of working
together
Questions with Complete
Solutions/ Verified
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 - -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 - -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 - -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 - -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 - -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 - -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 - -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 - -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 - -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 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 the next
day
d. Provide a PRN dose of an antacid to take with the Zithromax right
after
breakfast - -b. Instruct the client to eat his breakfast and take the
Zithromax two hours after
eating
-What instruction is most important for the nurse to provide a female
client who has
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 - -b. Treat
sexual partner (s) concurrently
-A primigravida at term comes to the prenatal clinic and tells the nurse
that she is having
contractions every 5 min. The nurse monitors the client for 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 to 30 seconds, with
mild intensity by
palpation. What action should the nurse take?
a. Tell the client to go directly to the hospital for admission to labor and
delivery for
active labor
b. Send the client home and instruct her to call the clinic when her
contractions occur
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 - -b. Send the client home and instruct
her to call the clinic when her contractions occur
, -Which instruction should the nurse provide to an elderly client who is
taking an ACE
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 - -d. Change the position slowly
-Assessment finding of a 3-hour-old newborn include: axillary
temperature of 97.7F, 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 - -c. Record the findings on the
flow sheet
-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 - -b. Search all
personal belongings
-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 meet separately 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 - -d. Ask the nurses to meet with the nurse-manager to identify
ways of working
together
