HESI RN
HESI RN CAT Exam Quizlet
1. The client is being taught how to take alendronate (Fosamax) for osteoporosis treatment. Which statement indicates that the client needs further teaching?
- A. I should take this medication at bedtime
- B. I will need to take this medication for at least 3 years
- C. I should sit up for 30 minutes after taking the medication
- D. I should take this medication with a full glass of water
Correct answer: A
Rationale: The correct answer is A because taking Fosamax at bedtime is incorrect. It should be taken in the morning with a full glass of water to prevent esophageal irritation. Choice B is correct; alendronate is typically taken for several years to treat osteoporosis. Choice C is correct as remaining upright for 30 minutes after taking Fosamax helps prevent esophageal irritation. Choice D is also correct as taking alendronate with a full glass of water is necessary to ensure proper absorption.
2. A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention?
- A. Place the client in reverse Trendelenburg position
- B. Prepare for intubation with an endotracheal tube
- C. Administer a pain medication to the client
- D. Instruct the client on deep breathing exercises
Correct answer: B
Rationale: In a client with a C-6 spinal injury exhibiting shallow respirations and dyspnea, these signs could indicate respiratory compromise and potential respiratory failure. Intubation with an endotracheal tube may be necessary to secure the airway and support adequate oxygenation. Placing the client in reverse Trendelenburg position, administering pain medication, or instructing on deep breathing exercises would not directly address the urgency of the respiratory distress in this situation, making them incorrect choices.
3. 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.
4. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?
- A. Use a 1-inch needle
- B. Select a large muscle for the injection
- C. Aspirate for blood return before injecting
- D. Massage the injection site
Correct answer: C
Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.
5. A 9-year-old boy with tetralogy of Fallot is being discharged following a cardiac catheterization. Which discharge instruction should the nurse provide the parents?
- A. Do not allow the child to return to school for at least one month
- B. Notify the healthcare provider if there is any drainage at the catheterization site
- C. Monitor the child's temperature and report any elevation
- D. Observe for any changes in the child's color or energy level
Correct answer: B
Rationale: The correct answer is to notify the healthcare provider if there is any drainage at the catheterization site. Drainage at the site can be a sign of infection, which needs prompt evaluation and treatment. Choices A, C, and D are not as crucial as identifying and reporting any drainage, which is more directly related to potential complications post-cardiac catheterization.
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