1- A 59-year-old male client is brought to the eme
Institution
1- A 59-year-old Male Client Is Brought To The Eme
HESI RN CAT EXAM 2023 V1&V2 QUESTIONS & ANSWERS|A
GRADED|20231- A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow
Coma Scale of 3. Based on this assessment, howshould the nurse characterize the client’s condition?
a. The client has increased intr...
1- A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow
Coma Scale of 3. Based on this assessment, howshould the nurse characterize the client’s condition?
a. The client has increased intracranial pressure
b. He has a good prognosis for recovery
c. This client is conscious, but is not oriented to time and place
d. He is in a coma, and has a very poor prognosisCorrect D
2- At a community health fair, a 50-year-old woman tells the nurse that she has anannual physical exam that
includes a clinical breast exam and an annual mammogram. How should the nurse respond?
a. Encourage the woman to explore her fears about breast cancer.
b. Ask the woman if she also performs monthly breast self- exams.
c. Commend the woman for adhering to the recommended cancer detectionguidelines.
d. Advise the woman that mammograms are only needed every two years ather age.
Correct B
3- Which assessment finding should indicate to the nurse that a client with arterialhypertension is
experiencing a cardiac complication?
a. Complaints of an occipital headache
b. A palpable dorsal is pedis pulse bilaterally
c. Complaints of shortness of breath on exertion
d. A blood pressure of 160/90Correct
C
4- A college student who is diagnosed with a vaginal infection and vulva irritationdescribes the vaginal
discharge as having a “cottage cheese” appearance.
Which prescription should the nurse implement first?
a. Cleanse perineum with warm soapy water 3 times per day
b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
c. Perform glucose measurement using a capillary blood sample
d. Obtain a blood specimen for sexually transmitted disease (STDs)Correct B
5- A client in acute renal failure has serum potassium of 7.5 mEq/L. Based on thisfinding, the nurse should
anticipate implementing which action?
a. Administer an IV of normal saline rapidly and NPH insulsubcutaneously.
, b. Administer a retention enema of Kayexalate
c. Add 40 mEq of KCL (potassium chloride) to present IV solution.
d. Administer a lidocaine bolus IV push.
Correct B
6- A client who had an intraosseous (IO) cannula placed by the healthcare providerfor an emergent fluid
resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale
and edematous. What action
should the nurse takes first?
a. Discontinue the IO infusion
b. Administer an analgesic via the IO site
c. Elevate the extremity with the IO site
d. Notify the healthcare providerCorrect A
7- The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit
needs to be transferred to male room for new admissions. Which client should the nurse
recommend for transfer to theantepartal unit?
a. A 45-year-old who has a chronic hepatitis B.
b. A 35-year-old with lupus erythematous
c. A 19-year-old who is diagnosed with rubella
d. A 25-year-old with herpes lesions of the vulvaCorrect B
8- A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS).
What should the nurse encourage this client to doto maintain sustained maximal inspiration?
a. Breathe into the spirometer using normal breath volumes
b. Exhale forcefully into the tubing for 3 to 5 seconds
c. Inspire deeply and slowly over 3 to 5 seconds
d. Perform IS breathing exercises every 6 hoursCorrect C
9- The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic
medication clozapine (Clozaril). Which statementshould the nurse provide?
a. You will be able to cope with your symptoms
b. It will help you function better in the community
c. The medication will help you think more clearly”
d. It will improve your grooming and hygieneCorrect C
10 – A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin
(Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the
client tells the nurse that he took hisinsulin but forgot to take his daily dose of the Zithromax an hour before
breakfast asinstructed. What action should the nurse implement?
a. Offer to obtain a new breakfast tray in an hour so the client can take theZithromax
b. Instruct the client to eat his breakfast and take the Zithromax two hours aftereating
c. Tell the client to skip that day’s dose and resume taking the Zithromax thenext day
d. Provide a PRN dose of an antacid to take with the Zithromax right afterbreakfast
Correct B
11- What instruction is most important for the nurse to provide a female client whohas just been diagnosed
with trichomoniasis?
a. Avoid douching
b. Treat sexual partner (s) concurrently
c. Avoid using moist washcloths when bathing
d. Postpone becoming pregnant until the infection is treatedCorrect B
12- A primigravida at term comes to the prenatal clinic and tells the nurse that she ishaving contractions every
5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the
client’s contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal
monitor,and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to30 seconds, with
mild intensity by palpation. What action should the nurse take?
a. Tell the client to go directly to the hospital for admission to labor and deliveryfor active labor
b. Send the client home and instruct her to call the clinic when her contractionsoccur 5 minutes apart for
one hour
c. Tell the client to check into the hospital within the next hour for evaluation ofpossible urinary tract
infection
Correct B
13- Which instruction should the nurse provide to an elderly client who is taking anACE inhibitor and a
calcium channel blocker?
a. Wear long-sleeved clothing when outdoors
b. Report the onset of sore throat
c. Eat plenty of potassium-rich food
d. Change the position slowlyCorrect
D
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 respiratoryrate at 42 breaths/min. Based on these findings,
what action should the nurse implement?
a. Place a pulse oximeter on the heel
b. Swaddle the infant in a warm blanket
c. Record the findings on the flow sheet
d. Check the vital signs in 15 minutesCorrect C
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?
a. Explain the programs guidelines
b. Search all personal belongings
c. Initiate psychosocial assessment
d. Review the healthcare’s provider’s prescriptionCorrect B
16- An experienced nurse tells the nurse-manager that working with a new graduateis 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?
a. Have both nurses meet separately with the staff mental health
consultant
b. Listen actively to both nurses and offer suggestions to solving dilemma
c. Ask the senior nurse to examine mentoring strategies used with the newgraduate
d. Ask the nurses to meet with the nurse-manager to identify ways of workingtogether
Correct D
17- Which nursing diagnosis has the highest priority when planning care for a clientin cardiogenic shock?
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