Hesi Exit Cat Exam 1, Answered-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 cl...
a client is comatose upon arrival to the emergency department after falling a roof the client flexes with painful stimuli
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Hesi Exit Cat Exam 1, Answered
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
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