HESI RN
HESI RN CAT Exam Quizlet
1. A nurse is preparing to administer an intramuscular injection to a client. Which action should the nurse take to reduce the client's risk of injury?
- A. Use a 1-inch needle
- B. Select a large muscle for the injection
- C. Aspirate for blood return before injecting
- D. Massage the injection site
Correct answer: C
Rationale: The correct answer is to aspirate for blood return before injecting. This action helps ensure that the needle is not in a blood vessel, reducing the risk of injury. Using a 1-inch needle (Choice A) is a standard length for intramuscular injections but does not directly reduce the risk of injury. Selecting a large muscle for the injection (Choice B) is important for proper medication absorption but does not directly reduce the risk of injury. Massaging the injection site (Choice D) can help with medication absorption but does not reduce the risk of injury.
2. At 0600 while admitting a woman for a scheduled repeat cesarean section (C-Section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Ensure preoperative lab results are available
- B. Start prescribed IV with lactated Ringer's
- C. Inform the anesthesia care provider
- D. Contact the client's obstetrician
Correct answer: C
Rationale: The correct action for the nurse to take first is to inform the anesthesia care provider. The patient's ingestion of coffee violates the NPO (nothing by mouth) guidelines before surgery, which increases the risk of aspiration during anesthesia. Informing the anesthesia care provider promptly allows for appropriate assessment and decision-making regarding the patient's anesthesia plan. Ensuring preoperative lab results, starting an IV, or contacting the obstetrician can be important steps but addressing the NPO violation and its implications on anesthesia safety take precedence.
3. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?
- A. annual flu vaccination status
- B. weight and height measurement
- C. total cholesterol level
- D. long bone deformity testing
Correct answer: B
Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.
4. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Unilateral lower leg pain.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 bpm.
- D. Soft, spongy fundus.
Correct answer: C
Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.
5. The nurse is conducting a process evaluation of a prevention education program for older adults who are at risk for substance abuse. Which data source provides the information the nurse needs to conduct this process evaluation?
- A. client's score on an alcohol screening instrument
- B. results of a urine drug and alcohol screen
- C. most recent community census data
- D. documentation of client education in the nursing record
Correct answer: D
Rationale: The correct answer is D. Documentation of client education in the nursing record provides information on the implementation and progress of the educational program, which is crucial for evaluating its process. Choices A and B focus on individual client assessment rather than program evaluation. Choice C, community census data, is not directly related to evaluating the process of the prevention education program for older adults at risk for substance abuse.