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. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.
3. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?
- A. Encourage the client to ambulate
- B. Apply a warm compress to the left leg
- C. Elevate the client's left leg
- D. Administer a prescribed anticoagulant
Correct answer: C
Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.
4. A patient with acute congestive heart failure is receiving high doses of a diuretic. On assessment, the nurse notes flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. Suspecting hyponatremia, what additional signs would the nurse expect to note in this patient if hyponatremia were present?
- A. Dry skin
- B. Decreased urinary output
- C. Hyperactive bowel sounds
- D. Increased specific gravity of the urine
Correct answer: C
Rationale: In a patient with hyponatremia, hyperactive bowel sounds are expected due to increased gastrointestinal motility. Dry skin (Choice A) is not a typical sign of hyponatremia. Decreased urinary output (Choice B) is more commonly associated with conditions like dehydration or renal issues, not specifically hyponatremia. Increased specific gravity of the urine (Choice D) is a sign of concentrated urine, which is not a characteristic finding in hyponatremia.
5. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?
- A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
- B. Provide space and privacy for the family to share their concerns about the client’s discharge
- C. Ask the social worker to encourage the family to clear the hallway
- D. Explain to the family the client’s need for privacy so that she can make independent decisions
Correct answer: B
Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.