Hesi Exit Cat Exam 2, Exam Questions & Answers-59 yo male client is brought to the emergency room where he is assessed to have a Glasgow coma scale of 3. Based on this assessment, how should the nurse characterize the clients’ condition?
a. client has increase icp
b. he has a good prognosis for...
Hesi Exit Cat Exam 2, Exam Questions & Answers
59 yo male client is brought to the emergency room where he is assessed to have a Glasgow
coma scale of 3. Based on this assessment, how should the nurse characterize the clients’
condition?
a. client has increase icp
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 prognosis - d. he is in a coma and has a very poor
prognosis
At a community health fair, 50 yo female tells the nurse that she has an annual physical exam
that includes a 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 performs monthly breast self-exams
c. recommend the women for adhering to the recommend cancer detection guidelines
d. advise the woman that mammogram are only needed every two yrs of age - b. ask the woman
if she performs monthly breast self exams
Which assessment finding should indicate to the nurse that client with arterial hypertension is
expericing a cardiac complication?
a. complaints of occipaital headache
b. palpable dorsal is pedis pulse bilaterally
c. complaints of SOB on exertion
d. bp of 160/90 - c. complaints of SOB on exertion
a college student who is diagnosed with vaginal infection and vulva irritation describes the
vaginal discharge as having 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 vaginally per applicator
c. perform glucose measurement using capillary blood sample
d. obtain a blood speciment for sexually transmitted disease - b. instill the first dose of nystatin
vaginally per applicator
a client in acute renal failure has serum potassium of 7.5. Based on this finding, the nurse should
anticapate implementing which action?
a. administer IV NS rapidly and NPH subq
b. administer a retention enema of kayexalate
c. add 40 KCL to present IV solution
d. administer lidocaine bolus IV push - b. administer a retention enema of kayexalate
,A client who had an intraosseous (IO) cannula placed by the healthcare provider for 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 provide - a. Discontinue the IO infusion
The nurse-manager of a perinatal unit is notified that one client from the Medical-surgical unit
needs to be transferred to make room for new admissions. Which client should the nurse
recommend for transfer to the antepartal 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 vulva - b. A 35-year-old with lupus erythematous
A nurse is teaching a client postoperative breathing techniques using an incentive spirometer
(IS). What should the nurse encourage this client to do to 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 hours - c. Inspire deeply and slowly over 3 to 5
seconds
The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic
medication clozapine (Clozaril). Which statement should 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 - c. The medication will help you think more
clearly
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 his insulin but
forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action
should the nurse implement?
a. Offer to obtain a new breakfast tray in an hour so the client can take the
Zithromax
b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating
c. Tell the client to skip that day's dose and resume taking the Zithromax the next day
d. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast - b. Instruct
the client to eat his breakfast and take the Zithromax two hours after
eating
, What instruction is most important for the nurse to provide a female client who has 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 treated - b. Treat sexual partner (s)
concurrently
A primigravida at term comes to the prenatal clinic and tells the nurse that she is having
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 to 30 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 delivery for active labor
b. Send the client home and instruct her to call the clinic when her contractions occur
5 minutes apart for one hour
c. Tell the client to check into the hospital within the next hour for evaluation of possible urinary
tract infection - b. Send the client home and instruct her to call the clinic when her contractions
occur
Which instruction should the nurse provide to an elderly client who is taking an ACE 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 slowly - d. Change the position slowly
Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7F, 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?
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 minutes - c. Record the findings on the flow sheet
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 prescription - b. Search all personal belongings
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