HESI CAT EXAM
( LATEST ) ACTUAL QUESTIONS AND ANSWERS
100% CORRECT
1. A GRANDSon is concern about the older clients happiness and so much
time is spent talking about the past what should the nurse respond to the
grandson:
Answer:
Reminiscing is a common activity in older adults that helps them to
stay connected
Rationale: The nurse should explain that reminiscing is normal and common
activity in older adults talking about the past helps older adult clients stay
connected to other people by providing a topic of conversation even if they don't
experiencemuch during the day
2. Family of an elderly Japanese woman is upset because the client has
not received any pain medication the nurse explains that the client never
complain about pain and did not write the pain and severe when assess what
should the nurse manager do:
Answer:
Explain that in the Japanese culture people often show a stoic response to pain so
that it is important to look for PHYSICAL clues
Rationale: individuals of Japanese descent will not complain about pain as they
do not want to dishonor themselves or their families some will either refuse pain
medication when offered therefore it is important to look for physical clothes like
(rocking, sweat on brows, elevated blood pressure) and input from the family when
assessing for pain
3. The nurse assessed audible expiratory wheezes over a clients lower
lobes what should the nurse do first after completing this assessment:
Answer:
Raise the Head of the bed to a 60° angle
Rationale: The client is demonstrating bilateral lower lobe wheezes the first thing
the nurse should do is raise the head of the bed to a 60° angle in order to improve
ventilation
4. The nurse is flushing a clients peripheral intravenous catheter saline lock
with sterile normal saline during the flush the nurse notes that resistance is
met what action should the nurse take:
, Answer:
Remove the saline lock and re-insert in another site
Rationale: The peripheral in a minute IV catheter device also known as a saline
lock is a device flushed with saline and applied to a PICC to maintain IV access
and patency. To maintain patency the lock should be flush with 3 mL of NS before
and after each medication administered, after blood draw, and every 12 hours with
the saline lock has been not been in use. While saline locks reduce the need to
insert IV lines, they do have a risk and should be removed 72 hours after insertion
to reduce the likelihood of infection
5. Infiltration:
Answer:
The infusion of fluid or medication outside the vein usually caused by poor IV
placement skin will appear swollen and cool to the touch
6. Hematoma:
Answer:
When blood from the veins pools into the surrounding tissues this
happens when the needle passes through the rain more than once or if pressure
is applied when removing the IV
7. air embolism:
Answer:
Extremely rare complication in which air travels through the IV line into the vein
and creates an envelope that could travel to the lungs or heart since the amount of
air tolerating is dependent on weight children are more at risk
of developing this complication
8. phlebitis:
Answer:
Inflammation of the rain caused by irritation solutions medication or the
angiocatheter being in place for days
9. superficial thrombophlebitis:
Answer:
Inflammation of a vein just below the surface of the skin caused by formation of a
thrombus this may cause pain, tendernessor hardening of the vein these often
resolved without intervention elevating the extremity and applying warm compress
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