HESI RN
HESI RN CAT Exam Quizlet
1. A healthcare provider is assessing a client who is receiving treatment for dehydration. Which assessment finding indicates that the client is responding to the treatment?
- A. Dry mucous membranes
- B. Increased urine output
- C. Decreased skin turgor
- D. Elevated heart rate
Correct answer: B
Rationale: Increased urine output is a positive sign indicating that the client is responding to the treatment for dehydration. It suggests that the client's kidneys are functioning better, helping to eliminate excess fluid and waste products from the body. Dry mucous membranes (Choice A) are a sign of dehydration, not improvement. Decreased skin turgor (Choice C) and elevated heart rate (Choice D) are also symptoms of dehydration and do not indicate a positive response to treatment.
2. A client is scheduled for a colonoscopy. Which preparation is the most important for the nurse to implement?
- A. Administer an enema before the procedure.
- B. Ensure the client is NPO after midnight.
- C. Encourage the client to drink clear liquids.
- D. Verify the client has completed the bowel preparation.
Correct answer: D
Rationale: The correct answer is to verify that the client has completed the bowel preparation. This step is crucial to ensure the colon is clear for accurate visualization during the procedure. Administering an enema before the procedure may not always be necessary and can be uncomfortable for the client. Ensuring the client is NPO after midnight is important, but verifying bowel preparation takes precedence. Encouraging the client to drink clear liquids is a part of the preparation process but not the most critical step compared to verifying completion of bowel preparation.
3. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?
- A. The ileostomy is draining blood-tinged urine.
- B. There is serous sanguineous drainage on the surgical dressing.
- C. The ileostomy stoma appears pale and cyanotic.
- D. Oxygen saturations are 92% on room air.
Correct answer: C
Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.
4. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?
- A. Decrease the oxytocin infusion rate
- B. Determine current cervical dilation
- C. Request placement of the epidural
- D. Give a bolus of intravenous fluids
Correct answer: D
Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.
5. The charge nurse of the critical care unit informed at the beginning of the shift that a less than optimal number of registered nurses would be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse?
- A. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter.
- B. A 48-year-old marathon runner with a central venous catheter experiencing nausea and vomiting due to electrolyte disturbance following a race.
- C. A 63-year-old chain smoker with chronic bronchitis receiving oxygen via nasal cannula and a saline-locked peripheral intravenous catheter.
- D. An 82-year-old client with Alzheimer's disease and a newly fractured femur with a Foley catheter and soft wrist restraints applied.
Correct answer: D
Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care. Choice A is less critical as the client is stable post-appendectomy. Choice B, though experiencing symptoms, is not at the same level of risk as the client in Choice D. Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in Choice D.