Nightingale College -HESI CAT exam studoc
Questions With Complete Solutions
59 yo 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 clients
condition?
a. client has increase icp
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
d. he is in a coma and has a very poor prognosis
at a community health fair, 50 yo female tells the nurse that she
has an annual physical exam that includes a 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 performs monthly breast self exams
c. recommend the women for adhering to the recommend cancer
detection guidelines
d. advise the woman that mammogram are only needed every
two yrs of age
b. ask the woman if she performs monthly breast self exams
which assessment finding should indicate to the nurse that client
with arterial hypertension is expericing a cardiac complication?
,a. complaints of occipaital headache
b. palpable dorsal is pedis pulse bilaterally
c. complaints of SOB on exertion
d. bp of 160/90
c. complaints of SOB on exertion
a college student who is diagnosed with vaginal infection and
vulva irritation describes the vaginal discharge as having 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 vaginally per applicator
c. perform glucose measurement using capillary blood sample
d. obtain a blood speciment for sexually transmitted disease
b. instill the first dose of nystatin vaginally per applicator
a client in acute renal failure has serum potassium of 7.5. based
on this finding, the nurse should anticapate implementing which
action?
a. administer IV NS rapidly and NPH subq
b. administer a retention enema of kayexalate
c. add 40 KCL to present IV solution
d. administer lidocaine bolus IV push
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
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 provide
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?
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
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?
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
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?
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
c. 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 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?
Questions With Complete Solutions
59 yo 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 clients
condition?
a. client has increase icp
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
d. he is in a coma and has a very poor prognosis
at a community health fair, 50 yo female tells the nurse that she
has an annual physical exam that includes a 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 performs monthly breast self exams
c. recommend the women for adhering to the recommend cancer
detection guidelines
d. advise the woman that mammogram are only needed every
two yrs of age
b. ask the woman if she performs monthly breast self exams
which assessment finding should indicate to the nurse that client
with arterial hypertension is expericing a cardiac complication?
,a. complaints of occipaital headache
b. palpable dorsal is pedis pulse bilaterally
c. complaints of SOB on exertion
d. bp of 160/90
c. complaints of SOB on exertion
a college student who is diagnosed with vaginal infection and
vulva irritation describes the vaginal discharge as having 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 vaginally per applicator
c. perform glucose measurement using capillary blood sample
d. obtain a blood speciment for sexually transmitted disease
b. instill the first dose of nystatin vaginally per applicator
a client in acute renal failure has serum potassium of 7.5. based
on this finding, the nurse should anticapate implementing which
action?
a. administer IV NS rapidly and NPH subq
b. administer a retention enema of kayexalate
c. add 40 KCL to present IV solution
d. administer lidocaine bolus IV push
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
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 provide
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?
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
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?
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
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?
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
c. 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 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?
