CAT EXAM 1-HESI EXIT 2022

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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT ANSWER A cervical laceration In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? - CORRECT ANSWER An elderly client with Alzheimer's disease complicated by dysphagia The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which action has the highest priority when the nurse implements this prescription? - CORRECT ANSWER Set the flow mete