a client with a history of congestive heart failure chf is admitted with fluid volume overload which assessment finding should the nurse report to the
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Nursing Elites

HESI RN

HESI RN CAT Exit Exam

1. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

2. The nurse is planning care for a client who is receiving radiation therapy for breast cancer. Which intervention is most important for the nurse to include?

Correct answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

3. The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

Correct answer: A

Rationale: The correct answer is A: Tachycardia, mental status change, and low urine output are early signs of shock. Tachycardia is the body's compensatory mechanism to maintain perfusion, mental status changes can indicate decreased cerebral perfusion, and low urine output reflects poor renal perfusion. Choices B, C, and D are incorrect. Warm skin, hypertension, and constricted pupils are not typical findings in the early stages of shock. Bradycardia, hypotension, and respiratory acidosis are more indicative of late-stage shock. Mottled skin, tachypnea, and hyperactive bowel sounds can be seen in various conditions but are not specific early signs of shock.

4. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

Correct answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

5. A 59-year-old 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 client's condition?

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

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