Cat exam 1-Hesi Exit Midterm Questions
With Complete\Verified Solutions 2025
Updated.
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? -
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? - 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? - 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? - 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? - 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? - Answer A
cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to assign to a
practical nurse? - Answer An elderly client with Alzheimer's disease complicated by dysphagia
,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? - 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? - 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? - 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? - 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? -
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? - 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? - 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? - 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? - Answer High risk for fluid volume
deficit related to temperature elevation
, genital herpes. Which nursing intervention has the highest priority? - 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? - 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? - Answer External manifestation of a spinal abnormality
What action should the nurse implement first when delegating nursing activities to an
unlicensed assistive personnel (UAP)? - 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? - Answer
A 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? - 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? - 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? - Answer Continue to monitor the client's labor progress
With Complete\Verified Solutions 2025
Updated.
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? -
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? - 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? - 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? - 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? - 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? - Answer A
cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to assign to a
practical nurse? - Answer An elderly client with Alzheimer's disease complicated by dysphagia
,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? - 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? - 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? - 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? - 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? -
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? - 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? - 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? - 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? - Answer High risk for fluid volume
deficit related to temperature elevation
, genital herpes. Which nursing intervention has the highest priority? - 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? - 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? - Answer External manifestation of a spinal abnormality
What action should the nurse implement first when delegating nursing activities to an
unlicensed assistive personnel (UAP)? - 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? - Answer
A 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? - 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? - 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? - Answer Continue to monitor the client's labor progress
