HESI RN
HESI RN CAT Exam Quizlet
1. The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?
- A. Provide educational materials on smoking cessation
- B. Offer blood pressure screening and monitoring
- C. Provide information on safe sex practices
- D. Discuss the importance of a healthy diet and exercise
Correct answer: B
Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.
2. A client with diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
- A. Administer 15 grams of carbohydrate
- B. Administer a glucagon injection
- C. Provide a snack with protein
- D. Encourage the client to rest
Correct answer: A
Rationale: In the scenario described, the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. The appropriate action for the nurse to take is to administer 15 grams of carbohydrate. Carbohydrate intake helps to rapidly raise blood sugar levels in cases of hypoglycemia. Administering a glucagon injection (Choice B) is not the initial treatment for mild hypoglycemia; it is typically used for severe hypoglycemia when the client is unable to consume oral carbohydrates. Providing a snack with protein (Choice C) is not the first-line intervention for hypoglycemia; immediate carbohydrate intake is necessary to raise blood sugar levels quickly. Encouraging the client to rest (Choice D) may be appropriate after administering the carbohydrate, but the priority is to address the low blood glucose levels by administering carbohydrates first.
3. The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct answer: A
Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.
4. The nurse is preparing to administer medications to a client with a nasogastric tube. Which action should the nurse take first?
- A. Check for tube placement
- B. Crush the medications
- C. Flush the tube with water
- D. Administer the medications
Correct answer: A
Rationale: The correct first action when administering medications to a client with a nasogastric tube is to check for tube placement. This is crucial to ensure that the medications are delivered to the correct location within the gastrointestinal tract. Checking the tube placement helps prevent complications such as medication entering the lungs if the tube is misplaced. Crushing the medications (choice B) or flushing the tube with water (choice C) should only be done after confirming the correct tube placement. Administering the medications (choice D) without verifying the tube placement can lead to serious consequences.
5. A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?
- A. Administer oxygen
- B. Perform chest physiotherapy
- C. Elevate the head of the bed
- D. Obtain a sputum specimen
Correct answer: A
Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.
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