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Exam (elaborations)

HESI RN CAT EXAM EXIT

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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, how should the nurse characterize the client's condition? He is in a coma, and has a very poor prognosis 2- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? Ask the woman if she also performs monthly breast self- exams. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication? Complaints of shortness of breath on exertion A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage cheese" appearance. Which prescription should the nurse implement first? b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator A client in acute renal failure has serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action? 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 sit. The skin around the site is pale and edematous. What action should the nurse takes first? 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? 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? 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? 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 hisbreakfast 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? Instruct the client to eat his breakfast and take the Zithromax two hours after eating 11-What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis? 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? Send the client home and instruct her to call the clinic when her contractions occur 5 minute


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