HESI CAT EXIT EXAM 4
( LATEST ) ACTUAL QUESTIONS AND ANSWERS
100% CORRECT
1. 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
2. 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
3. 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
4. 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
5. 17- Which nursing diagnosis has the highest priority when planning care
for a client in cardiogenic shock?:
Answer:
Ineffective Tissue Perfusion
6. 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
7. 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
8. 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
9. 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
10. 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:
b. Breath sounds
11. 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
, 12. 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
13. 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)
14. 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
15. 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
16. 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
17. 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
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