HESI New CAT exam Test Bank 100% Correct
A client with irritable bowel syndrome is recovering from surgery to create an ileostomy
what foods should the nurse instruct the client to avoid to reduce the risk of food
blockageANSWERS-Dried fruits & nuts
Rationale: dried fruits and nuts can cause a blockage in the small intestine the client
should be instructed to avoid these food items with an ileostomy
A client with malnutrition is assessed for osteomalacia what data show the nurse review
to determine their clients risk for this health problemANSWERS-Vitamin D levels
Rationale: Malnutrition has widespread affects on various organ systems osteomalacia
is defective mineralization of newly formed bones secondary to chronic deficiency of
vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide
the nurse with the most accurate information regarding this health problem
The nurse has determine an adolescent client needs reinforcement education about
prevention of a sickle cell crisis which instruction should the nurse include select all that
applyANSWERS-Wear warm clothes outside in cold weather
take your hydroxyurea (Droxia) daily as prescribed
Drink at least eight 12 ounces glasses of water a day
Get regular exercise but do not exercise so much that you become tired
Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle
cell disease. it occurs when the micro circulation is obstructed by sickling of the red
blood cells resulting in local tissue ischemia and severe pain. the three most common
identify triggers for the development of a vaso-occlusive crisis are hypoxemia,
dehydration, and body temperature changes
The nurse is caring for a client with schizophrenia who has refused they are risperidone
for the last week the client has been suspicious of nursing staff and periodically
aggressive for the past three days today the client broke a chair in their room and is
making verbal threats to the nurse and to other clients in the day wrong what is the first
action the nurse should takeANSWERS-Remove the other clients in nonessential staff
from the day room
Rationale: schizophrenia is a mental health disorder which causes hallucinations,
delusions, disorder thought process and impaired behavior function.
Safety for all staff clients and visitors is priority and potential violence situations
A nurse who normally works on a post surgical care unit has been asked to float to the
preoperative care unit what is the best response by the nurseANSWERS-I don't feel
totally comfortable floating so I would like to be paired with a resource nurse for my shift
,Rationale: The nurse has acknowledged their discomfort with floating and has also
identified a means of making a float shift nurse more comfortable and important part of
a successful float shift and identifying using resources on the float unit including a
partnership with a specific resource nurse for the shift to answer questions locate
supplies etc.
The nurse is preparing to administer medication through a client's nasalgastric tube
what will the nurse do first when administering these medicationsANSWERS-Assessed
for placement of the nasalgastric tube
Rationale: Before inserting any medication through the nasal gastric tube the nurse
needs to assess for correct placement of the tube
A client with an stage renal failure has requested no further treatment be provided when
the oldest daughter arrives to visit she is visibly upset that all dialysis treatments have
ended in demands that treatment be continue what should the nurse do it this
timeANSWERS-Explained that the client has requested that all treatments be stop
Rationale: The nurse is responsible for the following clients wishes for treatment the
daughter does not need to leave because there's no evidence that the client is upset
resuming Dallas treatment is not what the client wants and should not be done the
nurse can explain the change in treatments with a daughter and does not need to ask a
physician to have this conversation
The education department of a healthcare organization has design client education
sheet that explains the process of being admitted to the hospital in English Spanish and
French since these are the three major language is spoken by the hospitals client
population what does the client education sheet reflectsANSWERS-Sensitivity to the
diverse Client population
Rationale: By creating a client education sheet that can be read by the hospitals major
client population the education department is demonstrating sensitivity to the diverse
client population the education sheet does not reflect racial profiling stereotyping or
inappropriate categorizing of the clients population
The nurse is emptying the urinary collection bag for a client with history of HIV in which
sequence sure the nurse perform the following actions after the urinary collection bag
has been drainedANSWERS-Ensure urinary collection bag is placed below the clients
bladder
empty that your receptacle
remove PPE
Wash hands with soap & water
Document amount of urine collected
Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne
illnesses in cases of hematuria healthcare professionals including nurses need to
, completely situational risk assessment prior to each client interaction to determine risk
and choose the appropriate infection control strategy to minimize risk to themselves and
their client population according to the CDC
A GRANDSon is concern about the older clients happiness and so much time is spent
talking about the past what should the nurse respond to the grandsonANSWERS-
Reminiscing is a common activity in older adults that helps them to stay connected
Rationale: The nurse should explain that reminiscing is normal and common activity in
older adults talking about the past helps older adult clients stay connected to other
people by providing a topic of conversation even if they don't experience much during
the day
Family of an elderly Japanese woman is upset because the client has not received any
pain medication the nurse explains that the client never complain about pain and did not
write the pain and severe when assess what should the nurse manager doANSWERS-
Explain that in the Japanese culture people often show a stoic response to pain so that
it is important to look for PHYSICAL clues
Rationale: individuals of Japanese descent will not complain about pain as they do not
want to dishonor themselves or their families some will either refuse pain medication
when offered therefore it is important to look for physical clothes like (rocking, sweat on
brows, elevated blood pressure) and input from the family when assessing for pain
The nurse assessed audible expiratory wheezes over a clients lower lobes what should
the nurse do first after completing this assessmentANSWERS-Raise the Head of the
bed to a 60° angle
Rationale: The client is demonstrating bilateral lower lobe wheezes the first thing the
nurse should do is raise the head of the bed to a 60° angle in order to improve
ventilation
The nurse is flushing a clients peripheral intravenous catheter saline lock with sterile
normal saline during the flush the nurse notes that resistance is met what action should
the nurse takeANSWERS-Remove the saline lock and re-insert in another site
Rationale: The peripheral in a minute IV catheter device also known as a saline lock is a
device flushed with saline and applied to a PICC to maintain IV access and patency. To
maintain patency the lock should be flush with 3 mL of NS before and after each
medication administered, after blood draw, and every 12 hours with the saline lock has
been not been in use. While saline locks reduce the need to insert IV lines, they do
have a risk and should be removed 72 hours after insertion to reduce the likelihood of
infection
InfiltrationANSWERS-The infusion of fluid or medication outside the vein usually caused
by poor IV placement skin will appear swollen and cool to the touch
A client with irritable bowel syndrome is recovering from surgery to create an ileostomy
what foods should the nurse instruct the client to avoid to reduce the risk of food
blockageANSWERS-Dried fruits & nuts
Rationale: dried fruits and nuts can cause a blockage in the small intestine the client
should be instructed to avoid these food items with an ileostomy
A client with malnutrition is assessed for osteomalacia what data show the nurse review
to determine their clients risk for this health problemANSWERS-Vitamin D levels
Rationale: Malnutrition has widespread affects on various organ systems osteomalacia
is defective mineralization of newly formed bones secondary to chronic deficiency of
vitamin D it results in soft, weak bones that fracture easily vitamin D levels will provide
the nurse with the most accurate information regarding this health problem
The nurse has determine an adolescent client needs reinforcement education about
prevention of a sickle cell crisis which instruction should the nurse include select all that
applyANSWERS-Wear warm clothes outside in cold weather
take your hydroxyurea (Droxia) daily as prescribed
Drink at least eight 12 ounces glasses of water a day
Get regular exercise but do not exercise so much that you become tired
Rationale: Vaso-occlusive crisis is the most common clinical manifestation of a sickle
cell disease. it occurs when the micro circulation is obstructed by sickling of the red
blood cells resulting in local tissue ischemia and severe pain. the three most common
identify triggers for the development of a vaso-occlusive crisis are hypoxemia,
dehydration, and body temperature changes
The nurse is caring for a client with schizophrenia who has refused they are risperidone
for the last week the client has been suspicious of nursing staff and periodically
aggressive for the past three days today the client broke a chair in their room and is
making verbal threats to the nurse and to other clients in the day wrong what is the first
action the nurse should takeANSWERS-Remove the other clients in nonessential staff
from the day room
Rationale: schizophrenia is a mental health disorder which causes hallucinations,
delusions, disorder thought process and impaired behavior function.
Safety for all staff clients and visitors is priority and potential violence situations
A nurse who normally works on a post surgical care unit has been asked to float to the
preoperative care unit what is the best response by the nurseANSWERS-I don't feel
totally comfortable floating so I would like to be paired with a resource nurse for my shift
,Rationale: The nurse has acknowledged their discomfort with floating and has also
identified a means of making a float shift nurse more comfortable and important part of
a successful float shift and identifying using resources on the float unit including a
partnership with a specific resource nurse for the shift to answer questions locate
supplies etc.
The nurse is preparing to administer medication through a client's nasalgastric tube
what will the nurse do first when administering these medicationsANSWERS-Assessed
for placement of the nasalgastric tube
Rationale: Before inserting any medication through the nasal gastric tube the nurse
needs to assess for correct placement of the tube
A client with an stage renal failure has requested no further treatment be provided when
the oldest daughter arrives to visit she is visibly upset that all dialysis treatments have
ended in demands that treatment be continue what should the nurse do it this
timeANSWERS-Explained that the client has requested that all treatments be stop
Rationale: The nurse is responsible for the following clients wishes for treatment the
daughter does not need to leave because there's no evidence that the client is upset
resuming Dallas treatment is not what the client wants and should not be done the
nurse can explain the change in treatments with a daughter and does not need to ask a
physician to have this conversation
The education department of a healthcare organization has design client education
sheet that explains the process of being admitted to the hospital in English Spanish and
French since these are the three major language is spoken by the hospitals client
population what does the client education sheet reflectsANSWERS-Sensitivity to the
diverse Client population
Rationale: By creating a client education sheet that can be read by the hospitals major
client population the education department is demonstrating sensitivity to the diverse
client population the education sheet does not reflect racial profiling stereotyping or
inappropriate categorizing of the clients population
The nurse is emptying the urinary collection bag for a client with history of HIV in which
sequence sure the nurse perform the following actions after the urinary collection bag
has been drainedANSWERS-Ensure urinary collection bag is placed below the clients
bladder
empty that your receptacle
remove PPE
Wash hands with soap & water
Document amount of urine collected
Rationale: urine is a bodily fluid that can contain viruses bacteria and blood borne
illnesses in cases of hematuria healthcare professionals including nurses need to
, completely situational risk assessment prior to each client interaction to determine risk
and choose the appropriate infection control strategy to minimize risk to themselves and
their client population according to the CDC
A GRANDSon is concern about the older clients happiness and so much time is spent
talking about the past what should the nurse respond to the grandsonANSWERS-
Reminiscing is a common activity in older adults that helps them to stay connected
Rationale: The nurse should explain that reminiscing is normal and common activity in
older adults talking about the past helps older adult clients stay connected to other
people by providing a topic of conversation even if they don't experience much during
the day
Family of an elderly Japanese woman is upset because the client has not received any
pain medication the nurse explains that the client never complain about pain and did not
write the pain and severe when assess what should the nurse manager doANSWERS-
Explain that in the Japanese culture people often show a stoic response to pain so that
it is important to look for PHYSICAL clues
Rationale: individuals of Japanese descent will not complain about pain as they do not
want to dishonor themselves or their families some will either refuse pain medication
when offered therefore it is important to look for physical clothes like (rocking, sweat on
brows, elevated blood pressure) and input from the family when assessing for pain
The nurse assessed audible expiratory wheezes over a clients lower lobes what should
the nurse do first after completing this assessmentANSWERS-Raise the Head of the
bed to a 60° angle
Rationale: The client is demonstrating bilateral lower lobe wheezes the first thing the
nurse should do is raise the head of the bed to a 60° angle in order to improve
ventilation
The nurse is flushing a clients peripheral intravenous catheter saline lock with sterile
normal saline during the flush the nurse notes that resistance is met what action should
the nurse takeANSWERS-Remove the saline lock and re-insert in another site
Rationale: The peripheral in a minute IV catheter device also known as a saline lock is a
device flushed with saline and applied to a PICC to maintain IV access and patency. To
maintain patency the lock should be flush with 3 mL of NS before and after each
medication administered, after blood draw, and every 12 hours with the saline lock has
been not been in use. While saline locks reduce the need to insert IV lines, they do
have a risk and should be removed 72 hours after insertion to reduce the likelihood of
infection
InfiltrationANSWERS-The infusion of fluid or medication outside the vein usually caused
by poor IV placement skin will appear swollen and cool to the touch
