HESI RN
HESI RN CAT Exam Quizlet
1. Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea
Correct answer: A
Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.
2. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?
- A. Empty the bladder using an indwelling urinary catheter
- B. Increase the rate of the IV containing oxytocin (Pitocin)
- C. Assess for shock by determining the blood pressure
- D. Perform gentle massage at the level of the umbilicus
Correct answer: D
Rationale: Gentle massage at the level of the umbilicus is the initial intervention to help contract the uterus and reduce bleeding, which is crucial in managing postpartum hemorrhage. Emptying the bladder can help with fundal displacement, but massage should be done first to stimulate uterine contractions. Increasing the IV oxytocin rate is a possible intervention but not the initial priority. Assessing for shock is important, but addressing the uterine atony through massage takes precedence to prevent further hemorrhage.
3. During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?
- A. Fluid volume deficit (FVD)
- B. Fluid volume excess (FVE)
- C. Mild extracellular fluid (ECF) deficit
- D. Renal failure
Correct answer: A
Rationale: The nurse should suspect Fluid Volume Deficit (FVD) in this patient. Signs of FVD include elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin, which align with the patient's assessment findings. Choices B, C, and D are incorrect. Fluid Volume Excess (FVE) typically presents with bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild extracellular fluid (ECF) deficit usually manifests as thirst. Renal failure commonly results in Fluid Volume Excess (FVE) rather than Fluid Volume Deficit (FVD).
4. Which of the following laboratory values should the nurse monitor in a client with Cushing's syndrome?
- A. Blood glucose levels
- B. Serum calcium levels
- C. Serum potassium levels
- D. Serum sodium levels
Correct answer: A
Rationale: The correct answer is A: Blood glucose levels. In Cushing's syndrome, there is excess cortisol in the body which leads to increased blood glucose levels due to its effect on glucose metabolism. Elevated blood glucose levels are a common finding in individuals with Cushing's syndrome. Monitoring blood glucose levels is crucial as it helps in assessing and managing hyperglycemia in these patients. Choice B, serum calcium levels, is not typically a priority in monitoring for Cushing's syndrome. While abnormalities in calcium levels can occur in some endocrine disorders, hypercalcemia is not a hallmark of Cushing's syndrome. Choice C, serum potassium levels, and Choice D, serum sodium levels, are not directly associated with Cushing's syndrome. While electrolyte imbalances can occur in various conditions, they are not specifically linked to Cushing's syndrome as blood glucose levels are.
5. The nurse is assessing a client with left-sided heart failure. Which laboratory value is most concerning?
- A. Serum creatinine of 1.5 mg/dL
- B. Serum sodium of 136 mEq/L
- C. Serum potassium of 5.5 mEq/L
- D. Hemoglobin of 12 g/dL
Correct answer: C
Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client with left-sided heart failure as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias, which can exacerbate heart failure. Serum creatinine of 1.5 mg/dL is slightly elevated but not as immediately concerning as hyperkalemia. Serum sodium of 136 mEq/L is within the normal range. Hemoglobin of 12 g/dL is also within the normal range and not directly related to the client's left-sided heart failure.