Hesi Exit Cat 4 Exam 2022 with Correct Answers

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? - ANSWER He is in a coma, and has a very poor prognosis 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? - ANSWER Ask the woman if she also performs monthly breast self- exams. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication? - ANSWER Complaints of shortness of breath on exertion 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? - ANSWER b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator 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? - ANSWER 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 sit. The skin around the site is pale and edematous. What action should the nurse takes first? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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 hisbreakfast 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? - ANSWER Instruct the client to eat his breakfast and take the Zithromax two hours after eating 11-What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis? - ANSWER Treat sexual partner (s) concurrently 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? - ANSWER Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker? - ANSWER Change the position slowly 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? - ANSWER Record the findings on the flow sheet 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? - ANSWER Search all personal belongings 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? - ANSWER Ask the nurses to meet with the nurse-manager to identify ways of working together 17- Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock? - ANSWER Ineffective Tissue Perfusion 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? - ANSWER Impaired skin integrity related to altered circulation and pressure 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? - ANSWER Combine several legumes and grains such as beans and rice to form complete proteins 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? - ANSWER Red 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)? - ANSWER Monitor serum creatinine levels 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? - ANSWER d. Breath sounds 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? - ANSWER The nurse's feeling about this client 24-Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia? - ANSWER A middle-age male client in renal failure following an unsuccessful kidney transplant While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement? - ANSWER Measure the length of the apneic periods(longitude) 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? - ANSWER Ask the girl if she will be eating her breakfast this morning 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? - ANSWER Maintain possession of the evidence collection kit at all times until submitted to law enforcement 28- The nurse is caring for a 10-year-old who is diagnosed with acute glomerulonephritis. Which outcome is the priority or this child? - ANSWER Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr 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? - ANSWER Seek treatment for the sarcoma immediately 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? - ANSWER Centralized cyanosis and tachycardia when crying A postoperative client returns to the nursing unit following a ureter lithotomy via