Cat exam 1-Hesi Exit
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? - corret answerA 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? - corret
answerAnswer: 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? - corret answerCheck 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? - corret answerReassess
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? - corret 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? - corret answerA cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to assign
to a practical nurse? - corret answerAn 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? - corret answerSet 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? - corret answerC. 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? -
corret answer"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? - corret
answerEncourage 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? - corret answerSweating 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? - corret answerStage 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? - corret answerReport
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? - corret
answerAcute 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? - corret answerImpaired 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? - corret answerHigh 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? - corret answerDetermine 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? - corret answerNotify 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? -
corret answerExternal manifestation of a spinal abnormality What action should the
nurse implement first when delegating nursing activities to an unlicensed assistive
personnel (UAP)? - corret answerEvaluate 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? - corret answerA 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? - corret
answerHemoglobin 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? - corret answer21-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
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? - corret answerA 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? - corret
answerAnswer: 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? - corret answerCheck 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? - corret answerReassess
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? - corret 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? - corret answerA cervical laceration
In preparing assignments for the shift, which client is best for the charge nurse to assign
to a practical nurse? - corret answerAn 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? - corret answerSet 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? - corret answerC. 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? -
corret answer"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? - corret
answerEncourage 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? - corret answerSweating 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? - corret answerStage 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? - corret answerReport
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? - corret
answerAcute 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? - corret answerImpaired 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? - corret answerHigh 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? - corret answerDetermine 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? - corret answerNotify 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? -
corret answerExternal manifestation of a spinal abnormality What action should the
nurse implement first when delegating nursing activities to an unlicensed assistive
personnel (UAP)? - corret answerEvaluate 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? - corret answerA 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? - corret
answerHemoglobin 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? - corret answer21-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
