HESI RN
HESI RN CAT Exam Quizlet
1. The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client?
- A. Black
- B. Yellow
- C. Green
- D. Red
Correct answer: D
Rationale: The correct answer is D: Red. The client's vital signs indicate critical condition with a high pulse and low blood pressure, suggesting shock. A red tag is used to identify patients who require immediate attention and should be prioritized for treatment. Choice A, Black, is incorrect as it is typically used for deceased or expectant clients. Choice B, Yellow, is used for clients with non-life-threatening injuries who require medical care but can wait. Choice C, Green, is for clients with minor injuries who can wait the longest for treatment. Therefore, in this scenario, the client's condition warrants a red triage tag for immediate attention.
2. The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?
- A. Left brachial vein
- B. Right cephalic vein
- C. Dorsal side of the right wrist
- D. Right upper extremity
Correct answer: B
Rationale: The correct answer is B: Right cephalic vein. The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care. Choices A, C, and D are incorrect because the left brachial vein, the dorsal side of the right wrist, and the right upper extremity are not typically preferred sites for IV catheter insertion and may not provide optimal access or outcomes.
3. Which instruction about insulin administration should Nurse Kate give to a client?
- A. Always follow the same order when drawing up different insulins into the syringe.
- B. Shake the vials before withdrawing the insulin.
- C. Store unopened vials of insulin in the refrigerator at recommended temperatures.
- D. Discard the intermediate-acting insulin if it appears cloudy.
Correct answer: A
Rationale: The correct answer is A. Consistently following the same order when drawing up different insulins helps to prevent medication errors. Option B is incorrect because shaking insulin vials could cause bubbles to form, leading to inaccurate dosing. Option C is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness. Option D is incorrect because cloudy appearance in intermediate-acting insulin may indicate the presence of insulin crystals, which can affect its potency, but this does not necessarily mean it should be discarded without consulting a healthcare provider.
4. A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?
- A. Encourage the client to increase physical activity.
- B. Instruct the client to take rest breaks during walking.
- C. Apply warm compresses to the legs to improve circulation.
- D. Massage the affected leg to relieve the pain.
Correct answer: B
Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.
5. The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother?
- A. Give small amounts of baby food with each feeding.
- B. Thicken formula with cereal for each feeding.
- C. Dilute the child's formula with equal parts of water.
- D. Offer 10% dextrose in water between most feedings.
Correct answer: B
Rationale: Thickening formula with cereal is a recommended intervention for infants with gastroesophageal reflux disease (GERD) to help reduce vomiting and increase caloric intake. This modification can help the infant keep the food down better, reducing reflux symptoms while providing adequate nutrition. Giving small amounts of baby food with each feeding (Choice A) is not recommended for a 5-month-old with GERD as it may exacerbate symptoms. Diluting the child's formula with equal parts of water (Choice C) can lead to inadequate nutrition and is not advisable. Offering 10% dextrose in water between most feedings (Choice D) is not appropriate for managing GERD in infants and does not address the underlying issue of reflux.