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Cat exam 1-Hesi Exit|160 Questions and Answers
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Cat exam 1-Hesi Exit|160 Questions andAnswers
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? - -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? - -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? - -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? - -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? - -"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? -
-A cervical laceration
-In preparing assignments for the shift, which client is best for the charge
nurse to assign to a practical nurse? - -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? - -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? - -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? - -"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? - -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? - -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? - -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? - -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? - -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? - -
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? - -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? - -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? -
-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? - -External manifestation of
a spinal abnormality
-What action should the nurse implement first when delegating nursing
activities to an unlicensed assistive personnel (UAP)? - -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? - -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? - -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? - -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?
- -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? - -Keep the call bell within the client's reach
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