Hesi Exit 2022 - Cat exam 1 – Questions And
Answers
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 Ans:- 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 Ans:- 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 Ans:- 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 Ans:- 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 Ans:-
"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 Ans:- A cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to
assign to a practical nurse? Correct Ans:- 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 Ans:- Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an
injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the
nurse-manager who is supervising this nurse take first? Correct Ans:- C. Instruct
the nurse to select another injection site
,10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the
nurse provides home care instructions to the mother. Which statement by the
child's mother indicates that she understands home care treatment to promote
pulmonary function? Correct Ans:- "Chest physiotherapy should be performed at
least twice a day"
The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation?
Correct Ans:- Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1
diabetes mellitus. The parents correctly understands signs of hypoglycemia if they
include which symptom? Correct Ans:- Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an
immobile client. What documentation of this finding is best for the nurse to enter
into the client's record? Correct Ans:- Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on
her back and upper arms. The child's aunt tells the nurse that the child's parents
abuse drugs and alcohol. What intervention is most essential for the nurse to
implement? Correct Ans:- Report assessment findings to the proper legal
authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus.
He was diagnosed with a seizure disorder in childhood. What is the most likely
cause of his present condition? Correct Ans:- Acute withdrawal from
anticonvulsant medication
A Chinese-American client who just delivered a baby states that she will not be able
to take the prescribed sitz baths to help heal her episiotomy incision because this
will cause an unhealthy balance of cold and hot forces. When planning nursing care,
what nursing diagnosis has the highest priority? Correct Ans:- Impaired tissue
integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In
planning care for this child, which nursing diagnosis has the highest priority?
Correct Ans:- High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital herpes
with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is
experiencing an episode of genital herpes. Which nursing intervention has the
highest priority? Correct Ans:- Determine if the client has taken acyclovir (Zovirax)
for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription for
paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to implement?
Correct Ans:- Notify the healthcare provider that the client is currently taking
Marplan
, While performing a skin inspection on a newborn, the nurse finds a small dimple
and a dark tuft of hair in the lumbosacral area of the infant's back. What is the most
likely indication of this finding? Correct Ans:- External manifestation of a spinal
abnormality
What action should the nurse implement first when delegating nursing activities to
an unlicensed assistive personnel (UAP)? Correct Ans:- Evaluate the experience of
the UAP
A female resident of a long-term care facility is being admitted to the medical
department. The client has a fractured hip and has methicillin-resistant
staphylococcus aureus (MRSA). Which room should the charge nurse assign this
client? Correct Ans:- A semi-private room with a client who also has methicillin-
resistant staphylococcus
aureus (MRSA)
The nurse is preparing a client for surgery. Which finding indicates that the client is
ready to proceed to the operating room (OR) for a scheduled surgical procedure?
Correct Ans:- Hemoglobin 10.1 grams
The nurse is preparing to administer an intramuscular injection in the ventrogluteal
site of a client who weighs 80 kg. What size needle should the nurse select?
Correct Ans:- 21-gauge, 1.5-inch needle
A client at 38-weeks gestation is in active labor, and a vaginal birth after Cesarean
section (VBAC) is planned. Vaginal exam indicates that the client is 6 cm dilated,
90% effaced, and at station 0 with intact membranes. As the client's contraction
become stronger, the fetal heart rate decelerates during the contractions but
returns to baseline. What action should the nurse take? Correct Ans:- Continue to
monitor the client's labor progress
An elderly client with limited mobility reports frequent episodes of nocturia. To
reduce the risk for urinary incontinence, what action should the nurse implement?
Correct Ans:- Keep the call bell within the client's reach
Which diagnostic tests are most important for the nurse to monitor when providing
care for a client with a bowel obstruction? Correct Ans:- Serum electrolytes
28. A 72-year-old male client reports that he has felt depressed since his wife died
six months ago. What question is most important for the nurse to ask this client?
Correct Ans:- "Have you ever felt like hurting yourself?"
After administering the first dose of newly prescribed to four clients within a thirty
minute time frame, the nurse evaluates each client for therapeutic responses or any
adverse reactions. Which medication should the nurse evaluate first? Correct Ans:-
HYdromorphone (Dilaudid)
Answers
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 Ans:- 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 Ans:- 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 Ans:- 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 Ans:- 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 Ans:-
"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 Ans:- A cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to
assign to a practical nurse? Correct Ans:- 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 Ans:- Set the flow meter
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an
injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the
nurse-manager who is supervising this nurse take first? Correct Ans:- C. Instruct
the nurse to select another injection site
,10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the
nurse provides home care instructions to the mother. Which statement by the
child's mother indicates that she understands home care treatment to promote
pulmonary function? Correct Ans:- "Chest physiotherapy should be performed at
least twice a day"
The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation?
Correct Ans:- Encourage physical activity
The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1
diabetes mellitus. The parents correctly understands signs of hypoglycemia if they
include which symptom? Correct Ans:- Sweating
The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an
immobile client. What documentation of this finding is best for the nurse to enter
into the client's record? Correct Ans:- Stage 1 pressure ulcer on sacrum
When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on
her back and upper arms. The child's aunt tells the nurse that the child's parents
abuse drugs and alcohol. What intervention is most essential for the nurse to
implement? Correct Ans:- Report assessment findings to the proper legal
authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus.
He was diagnosed with a seizure disorder in childhood. What is the most likely
cause of his present condition? Correct Ans:- Acute withdrawal from
anticonvulsant medication
A Chinese-American client who just delivered a baby states that she will not be able
to take the prescribed sitz baths to help heal her episiotomy incision because this
will cause an unhealthy balance of cold and hot forces. When planning nursing care,
what nursing diagnosis has the highest priority? Correct Ans:- Impaired tissue
integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In
planning care for this child, which nursing diagnosis has the highest priority?
Correct Ans:- High risk for fluid volume deficit related to temperature elevation
During the first trimester of pregnancy, a client who was treated for genital herpes
with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is
experiencing an episode of genital herpes. Which nursing intervention has the
highest priority? Correct Ans:- Determine if the client has taken acyclovir (Zovirax)
for this outbreak of genital herpes
The nurse is obtaining a medication history for a client with a new prescription for
paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to implement?
Correct Ans:- Notify the healthcare provider that the client is currently taking
Marplan
, While performing a skin inspection on a newborn, the nurse finds a small dimple
and a dark tuft of hair in the lumbosacral area of the infant's back. What is the most
likely indication of this finding? Correct Ans:- External manifestation of a spinal
abnormality
What action should the nurse implement first when delegating nursing activities to
an unlicensed assistive personnel (UAP)? Correct Ans:- Evaluate the experience of
the UAP
A female resident of a long-term care facility is being admitted to the medical
department. The client has a fractured hip and has methicillin-resistant
staphylococcus aureus (MRSA). Which room should the charge nurse assign this
client? Correct Ans:- A semi-private room with a client who also has methicillin-
resistant staphylococcus
aureus (MRSA)
The nurse is preparing a client for surgery. Which finding indicates that the client is
ready to proceed to the operating room (OR) for a scheduled surgical procedure?
Correct Ans:- Hemoglobin 10.1 grams
The nurse is preparing to administer an intramuscular injection in the ventrogluteal
site of a client who weighs 80 kg. What size needle should the nurse select?
Correct Ans:- 21-gauge, 1.5-inch needle
A client at 38-weeks gestation is in active labor, and a vaginal birth after Cesarean
section (VBAC) is planned. Vaginal exam indicates that the client is 6 cm dilated,
90% effaced, and at station 0 with intact membranes. As the client's contraction
become stronger, the fetal heart rate decelerates during the contractions but
returns to baseline. What action should the nurse take? Correct Ans:- Continue to
monitor the client's labor progress
An elderly client with limited mobility reports frequent episodes of nocturia. To
reduce the risk for urinary incontinence, what action should the nurse implement?
Correct Ans:- Keep the call bell within the client's reach
Which diagnostic tests are most important for the nurse to monitor when providing
care for a client with a bowel obstruction? Correct Ans:- Serum electrolytes
28. A 72-year-old male client reports that he has felt depressed since his wife died
six months ago. What question is most important for the nurse to ask this client?
Correct Ans:- "Have you ever felt like hurting yourself?"
After administering the first dose of newly prescribed to four clients within a thirty
minute time frame, the nurse evaluates each client for therapeutic responses or any
adverse reactions. Which medication should the nurse evaluate first? Correct Ans:-
HYdromorphone (Dilaudid)
