HESI RN
HESI RN CAT Exam Quizlet
1. A nurse is caring for a client with a new colostomy. Which instruction should the nurse include in the client's teaching plan?
- A. Change the ostomy appliance daily
- B. Empty the ostomy pouch when it is one-third full
- C. Rinse the ostomy pouch with warm water
- D. Apply a skin barrier to the peristomal skin
Correct answer: B
Rationale: The correct instruction the nurse should include in the client's teaching plan is to empty the ostomy pouch when it is one-third full. This practice helps prevent leakage and skin irritation by maintaining an appropriate pouching system. Changing the ostomy appliance daily (Choice A) is not necessary unless leakage or other issues occur. Rinsing the ostomy pouch with warm water (Choice C) is not a recommended practice as it may cause damage to the pouch. Applying a skin barrier to the peristomal skin (Choice D) is important but not the most crucial instruction in this scenario.
2. The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which clinical finding is most concerning?
- A. Blood pressure of 110/70 mmHg
- B. Heart rate of 110 beats per minute
- C. Fever of 100.4°F
- D. Respiratory rate of 24 breaths per minute
Correct answer: C
Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis because it may indicate an underlying infection that requires immediate attention. Elevated body temperature can be a sign of systemic infection, which can quickly worsen in individuals with compromised renal function. Monitoring for infection is crucial in ESRD patients to prevent complications. Choices A, B, and D are not as immediately concerning in this context. While variations in blood pressure, heart rate, and respiratory rate should be monitored, they are not as indicative of a potentially severe issue as an unexplained fever in this scenario.
3. A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching?
- A. I will take my pills every day at the same time.
- B. I will be certain to avoid alcohol consumption.
- C. I have already called my family to pick up a Medic-Alert bracelet.
- D. I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated.
Correct answer: D
Rationale: Ecotrin is an aspirin-containing product and should be avoided. Clients should avoid alcohol consumption, take prescribed medication at the same time each day, and use a Medic-Alert bracelet for emergency information.
4. 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?
- A. Encourage the client to use sunscreen
- B. Apply lotion to the radiated area
- C. Keep the area dry and clean
- D. Encourage the client to exercise the arm
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.
5. During which stage of photosynthesis is solar energy converted to chemical energy?
- A. During phosphate synthesis
- B. During light reactions
- C. During the Krebs cycle
- D. During the Calvin cycle
Correct answer: B
Rationale: The correct answer is B, during the light reactions. During the light reactions of photosynthesis, solar energy is absorbed by chlorophyll and converted into chemical energy in the form of ATP and NADPH. Choice A is incorrect as phosphate synthesis does not involve the conversion of solar energy. Choice C, the Krebs cycle, is a part of cellular respiration, not photosynthesis. Choice D, the Calvin cycle, is responsible for fixing carbon dioxide into carbohydrates and does not involve the direct conversion of solar energy to chemical energy.