a client diagnosed with a deep vein thrombus dvt followed by a diagnosis of pulmonary embolism pe is receiving heparin via an infusion pump at a rate
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Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?

Correct answer: A

Rationale: Choice A is the best response because it educates the client about the role of heparin in preventing future clot formation rather than dissolving the existing clot. This helps the client understand the medication's function and the importance of closely monitoring for signs of bleeding, a common side effect of heparin therapy. Choice B acknowledges the client's concern but does not provide accurate information about heparin's mechanism of action. Choice C is premature as it suggests transitioning to home therapy without addressing the client's concerns or explaining heparin's purpose. Choice D does not address the client's statement and instead questions their desire to leave the hospital.

2. When preparing an educational program for adolescents about the risks of multiple sexual partners, which information is most important to include?

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.

3. At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?

Correct answer: B

Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.

4. What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Correct answer: B

Rationale: The correct answer is B: Inspection of the mouth. This assessment technique is crucial for monitoring gingival hyperplasia, a common side effect of phenytoin. Bladder palpation (choice A) is not relevant to monitoring for phenytoin's side effects. Blood glucose monitoring (choice C) is important for clients with diabetes but is not specifically related to phenytoin. Auscultation of breath sounds (choice D) is more relevant for assessing respiratory conditions, not side effects of phenytoin.

5. When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?

Correct answer: C

Rationale: The correct answer is C: Select a large, deep muscle mass. When administering an intramuscular injection with a painful medication volume of 3 ml, selecting a large and deep muscle mass is crucial. This intervention reduces discomfort for the patient and ensures proper absorption of the medication. Choice A is incorrect because instilling the medication quickly can increase discomfort. Choice B is incorrect as inserting the needle slowly may prolong the discomfort. Choice D is incorrect as using a short, small gauge needle may not be suitable for delivering 3 ml of medication effectively into the muscle.

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