HESI RN CAT EXAM EXIT

HESI RN CAT EXAM EXIT 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? a. The client has increased intracranial pressure 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 Correct D 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? a. Encourage the woman to explore her fears about breast cancer. b. Ask the woman if she 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 at her 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 describes the 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 this finding, 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 bolus IV push. Correct B 6- 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 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 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 Correct C 9- 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” 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 the next 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 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 Correct B 12- 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 Correct B 13- 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 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 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 Correct D 17- Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock? a. Risk for imbalance body temperature b. Excess fluid 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 left side paralysis Correct B 19- The nurse offers diet teaching to a female college student who was diagnosed with 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 of amino acids b. Take vitamin K 10mg PO daily to enhance production of red blood cells c. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores d. Combine several legumes and grains such as beans and rice to form complete proteins Correct D 20- The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag 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 develop a therapeutic relationship with this client, which information is most important for the nurse to determine? a. The family’s reaction 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, the nurse 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 to an 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 if she 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 submitted to 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 client is diagnosed with Ewing’s sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client? a. Take analgesics regularly 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 via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client? a. Ineffective airway clearance b. Altered nutrition less than 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 maximum dosage 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 and with 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. Remains free of injury c. Remains free of infection d. Maintains effective breathing pattern Correct D 34- When the nurse enters the room to change the dressing of a male client with cancer, he asks, “Have you ever been with someone when they died?” What is the nurse’s best response to him? a. “Yes I have. Do you have some questions about dying?” b. “Several times. Now, let’s get your dressing changed” c. “A few times. It was peaceful and there was no pain” d. “Yes, but you’re doing great. Are you concerned about dying?” Correct A 35- A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention? a. Put the client in reverse Trendelenburg position b. Prepare for intubation with an endotracheal tube c. Administer a pain medication to the client d. Instruct the client on deep breathing exercises Correct B 36- When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record. Ans: 42 37- When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll o the bottom right corner of each tab to view all information contained in the client’s medical record. ANS 5 38- The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client? a. Oral contraceptives should be started to prevent an unwanted pregnancy b. Children have more upper respiratory infections if exposed to smoke at home c. Cigarette smoking increases the risk for peptic ulcers and emphysema d. A diaphragm and condom provide effective contraception when used together Correct D 39- An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority? a. Self-care deficit b. Disturbed sleep pattern c. Disturbed thought processes d. Imbalanced nutrition Correct D 40- A 9 year-old received a short arm cast for a right radius. To relieve itching under the child’s cast, which instructions should the nurse provide to the parents? a. Blow cool air from a hair dryer under the cast b. Twist the cast back and forth c. Shake powder into the cast d. Push a pencil under the cast edge Correct A 41- A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. The nurse should allow this client to have how much oral intake during the next 24 hours? a. Encourage oral fluids as tolerated b. Decrease oral intake to 200 ml c. Allow the client to have exactly 400 ml oral intake d. Limit oral intake to 900 to 1,000 ml Correct D 42- A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks what happened. She doesn’t respond. What should the nurse do next? a. Find supplies to put a dressing on the client’s wrist b. Take the client to a room for supervision by staff c. Call the healthcare provider to report the client’s behavior d. Go find a staff to stay in the room with the client Correct B 43- What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)? a. Bladder palpation b. Inspection of the mouth c. Blood glucose monitoring d. Auscultation of breath sounds Correct B 44- The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor? a) Calcium b) Sodium c) Chloride d) Potassium Correct A 45- The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “What do you think you’re doing?” How should the nurse respond? a.” I cannot give you this medication until you calm down” b. “This shot will help relieve the pain in your feet.” c. “Would you prefer to learn to administer your own shot?” d. “You will feel calmer and less jittery after this shot” Correct B 46- When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement? a. Instill the medication quickly b. Insert the needle slowly c. Select a large, deep muscle mass d. Use a short small gauge needle Correct C 47- Several clients on a telemetry unit are schedule for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is a. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus b. Ambulatory following coronary artery bypass graft surgery performed six days ago. c. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day d. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea Correct A 48- The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify? a. Tachycardia, mental status change, and low urine output b. Warm skin, hypertension, and constricted pupils c. Bradycardia, hypotension, and respiratory acidosis d. Mottled skin, tachypnea and hyperactive bowel sounds Correct A 49- The nurse is making assignments for a new graduate from a practical nursing program that is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client a. Whose discharge has been delayed because of a postoperative infection b. With poorly controlled type 2 diabetes who is sliding scale for insulin administration c. Newly admitted with a head injury who requires frequent assessments d. Who is receiving IV heparin that is regulated based on protocol Correct A 50- Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement? a. Require the other nurses to cross-train for obstetrics b. Propose a method for self-staffing labor and delivery c. Remind nurses that floating is an administrative policy d. Encourage nurses to share their feelings with administration Correct B