HESI CAT EXAM
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
blockage - correct answerDried 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 problem - correct
answerVitamin 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 apply - correct answerWear 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 take - correct
answerRemove 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 nurse - correct answerI 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 medications - correct answerAssessed 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 time -
correct answerExplained 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 reflects - correct answerSensitivity 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 drained - correct
answerEnsure 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 grandson - correct answerReminiscing 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 do - correct answerExplain 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
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
blockage - correct answerDried 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 problem - correct
answerVitamin 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 apply - correct answerWear 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 take - correct
answerRemove 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 nurse - correct answerI 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 medications - correct answerAssessed 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 time -
correct answerExplained 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 reflects - correct answerSensitivity 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 drained - correct
answerEnsure 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 grandson - correct answerReminiscing 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 do - correct answerExplain 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
