HESI RN
HESI RN CAT Exam Quizlet
1. 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.
2. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?
- A. Limit sodium intake to reduce fluid retention
- B. Consume high-protein foods to strengthen the heart
- C. Increase potassium intake to manage blood pressure
- D. Increase fluid intake to promote hydration
Correct answer: A
Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.
3. Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?
- A. The one with the clamp and no needle
- B. A butterfly needle
- C. A non-coring (Huber) needle
- D. A standard hypodermic needle
Correct answer: C
Rationale: The correct needle to use for administering intravenous fluids via an implanted port is a non-coring (Huber) needle. This type of needle is specifically designed to access implanted ports without coring the septum, which helps prevent damage. Choice A, the one with the clamp and no needle, is incorrect as it does not describe a needle suitable for accessing an implanted port. Choice B, a butterfly needle, is not typically used for accessing implanted ports. Choice D, a standard hypodermic needle, is not ideal for accessing ports as it can damage the septum.
4. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?
- A. Pan-seared catfish.
- B. Pepperoni pizza.
- C. Deep-fried shrimp.
- D. Beef strips with gravy.
Correct answer: D
Rationale: When a client is taking MAO inhibitors like phenelzine, foods containing tyramine should be avoided. Tyramine-rich foods can interact with MAO inhibitors and lead to a hypertensive crisis. Beef strips with gravy contain tyramine, making choice D the correct answer. Choices A, B, and C do not contain high levels of tyramine and are not specifically contraindicated with MAO inhibitors.
5. The caregiver is teaching a group of parents about injury prevention for toddlers. Which statement by a parent indicates a need for further teaching?
- A. I will keep all cleaning supplies locked away.
- B. I will teach my child how to swim this summer.
- C. I will make sure my child wears a helmet while riding a tricycle.
- D. I will place my child in a car seat for every car ride.
Correct answer: B
Rationale: Teaching children how to swim is valuable, but parental supervision around water is essential to prevent drowning. It's crucial to emphasize constant supervision when young children are near water, regardless of their swimming abilities. The other choices (A, C, and D) demonstrate appropriate safety measures for injury prevention in toddlers, such as securing cleaning supplies, ensuring helmet use during tricycle rides, and using a car seat for every car ride.