HESI RN
HESI RN CAT Exam Quizlet
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?
- A. Decrease the oxygen flow rate
- B. Increase the oxygen flow rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct answer: A
Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.
2. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?
- A. Assess the need for continued restraint
- B. Check the client for urinary incontinence
- C. Determine skin integrity under the vest
- D. Perform range-of-motion exercises on extremities
Correct answer: A
Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.
3. The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?
- A. Oral contraceptives should be started to prevent an unwanted pregnancy
- B. Children are more prone to upper respiratory infections if exposed to smoke at home
- C. Cigarette smoking increases the risk for peptic ulcers and emphysema
- D. A diaphragm and condom provide effective contraception when used together
Correct answer: D
Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.
4. A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?
- A. Maintain the client on bed rest
- B. Apply warm, moist compresses to the legs
- C. Encourage early ambulation
- D. Massage the legs daily
Correct answer: C
Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.
5. When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?
- A. Condoms provide reliable protection against sexually transmitted infections.
- B. Having multiple sexual partners increases the risk of contracting sexually transmitted infections.
- C. The use of oral contraceptives can reduce the risk of sexually transmitted infections.
- D. Having multiple sexual partners increases the risk of developing cancer.
Correct answer: B
Rationale: The correct answer is B because having multiple sexual partners significantly increases the risk of contracting sexually transmitted infections (STIs). This information is crucial for adolescents to understand the potential consequences of engaging in risky sexual behaviors. Choice A is incorrect because while condoms are important for protection, they are not 100% effective. Choice C is incorrect as oral contraceptives do not protect against STIs. Choice D is incorrect as the immediate concern for adolescents in this context is the risk of STIs rather than cancer.
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