HESI CAT Exam

HESI CAT Exam Related

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After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?

  • A. Monitor for signs of depression
  • B. Apply sequential compression stockings
  • C. Provide a wide variety of meal choices
  • D. Observe for signs of depression
Correct Answer: D

Rationale: Observing for signs of depression is crucial in this patient's plan of care as depression can impact his overall recovery and management post-surgery. Depression is common in individuals struggling with weight management, diabetes mellitus, and hypertension. Monitoring for urinary incontinence (Choice A) is not the priority in this case as the patient is undergoing gastroplasty for weight management, not a urinary issue. Applying sequential compression stockings (Choice B) is important for preventing deep vein thrombosis in immobile patients but is not the priority in this scenario. Providing a wide variety of meal choices (Choice C) is not the most crucial intervention at this stage, as post-gastroplasty dietary restrictions are essential for successful weight management.

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A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Enter a numeric value only. If rounding is required, round to the nearest tenth)

  • A. 4.5
Correct Answer: A

Rationale: To calculate the total dose of baclofen needed in a 24-hour period, multiply 15 mg by 3 doses, which equals 45 mg. Since the tablets are available in 10 mg strength, divide the total dose needed (45 mg) by the strength of each tablet (10 mg), which equals 4.5 tablets. Rounding off to the nearest tenth, the nurse should administer 4.5 tablets of 10 mg baclofen per day. Therefore, choice A is correct. Choices B, C, and D are irrelevant as they are not provided.

Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?

  • A. Confusion
  • B. Check neuro vital signs every 4 hours.
  • C. Maintain intravenous access.
  • D. Keep the suture line clean and dry.
Correct Answer: C

Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.

A child with heart failure (HF) is taking digitalis. Which sign indicates to the nurse that the child may be experiencing digitalis toxicity?

  • A. Tachycardia
  • B. Dyspnea
  • C. Vomiting
  • D. Muscle cramps
Correct Answer: C

Rationale: Vomiting is a common sign of digitalis toxicity and should be closely monitored. While tachycardia is a common sign of heart failure, it is not typically associated with digitalis toxicity (Choice A). Dyspnea (Choice B) and muscle cramps (Choice D) are not specific signs of digitalis toxicity and can be present in other conditions. Therefore, the presence of vomiting should raise concerns about digitalis toxicity in the child with heart failure.

The client demonstrates an understanding of sliding scale insulin administration instructions by performing the procedure in which order?

  • A. Obtain blood glucose level
  • B. Verify the insulin prescription
  • C. Draw insulin into insulin syringe
  • D. Cleanse the selected site
Correct Answer: A

Rationale: The correct order for the client to perform the procedure is to first obtain the blood glucose level. This step is crucial as it helps determine the appropriate dose of insulin based on the sliding scale. Verifying the insulin prescription, drawing insulin into the syringe, and cleansing the selected site are important steps in the process but should follow after obtaining the blood glucose level. Therefore, options B, C, and D are incorrect in terms of the initial steps required for sliding scale insulin administration.

An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take?

  • A. Tell the client he is required by law to inform his sexual partners of his HIV status
  • B. Counsel the client about the importance of notifying his sexual partner
  • C. Inform the wife of her health risk related to her husband's HIV results
  • D. Report the client's status as a sexually transmitted case to the health department
Correct Answer: B

Rationale: The nurse should counsel the client on the importance of notifying partners about HIV status while respecting confidentiality. Mandatory partner notification laws vary by jurisdiction, so option A cannot be universally applied. Breaching patient confidentiality, as suggested in option C, is unethical. Reporting the client's status to the health department without consent, as in option D, is not appropriate as HIV status is confidential information and is not automatically reported as a sexually transmitted case.

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