HESI RN CAT Exit Exam 1

HESI RN CAT Exit Exam 1 Related

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A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?

  • A. Remind the client that it is also important to schedule an annual mammogram
  • B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure
  • C. Encourage the client to perform BSE 2 to 3 days after the menstrual period ends
  • D. Instruct the client to continue with her regular monthly exams as she is doing
Correct Answer: C

Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination. Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE. Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review. Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.

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Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?

  • A. Dorsiflexes the right foot and left on command
  • B. A 3 by 5 cm ecchymosis area covering the right calf
  • C. Right calf is 3 cm larger in circumference than the left
  • D. Bilateral lower extremity has 3+ pitting edema
Correct Answer: C

Rationale: The correct answer is C because a significant increase in the circumference of the right calf compared to the left calf is a classic sign of deep vein thrombosis (DVT). Option A is incorrect as dorsiflexing the right foot and left on command does not specifically indicate DVT. Option B describes an ecchymosis area which is more indicative of a bruise rather than DVT. Option D suggests bilateral lower extremity edema, which is not specific to DVT and can be seen in various conditions such as heart failure or renal issues.

A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

  • A. Monitor the client's respiratory status
  • B. Teach the client how to use the PCA pump
  • C. Evaluate the client's pain level
  • D. Assess the client's pain level
Correct Answer: A

Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.

A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?

  • A. Maintain a quiet environment
  • B. Ensure the linens are clean and dry
  • C. Place an air deodorizer in the room
  • D. Measure all emesis accurately
Correct Answer: D

Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.

The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?

  • A. Obtain a speech therapy consult
  • B. Elevate the head of the bed
  • C. Check the client's lung sounds
  • D. Implement aspiration precautions
Correct Answer: B

Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.

In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

  • A. Pink lips and tongue with cyanotic hands and feet
  • B. Respiration rate of 40 and heart rate of 144
  • C. Centralized cyanosis and tachycardia when crying
  • D. Desquamation from areas of cracked, parchment-like skin
Correct Answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

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