HESI CAT Exam

HESI CAT Exam Related

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A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

  • A. Observe for bleeding side effects related to heparin therapy.
  • B. Assess blood pressure and heart rate at least every 4 hours.
  • C. Measure calf girth to evaluate edema in the affected leg.
  • D. Encourage mobilization to prevent pulmonary embolism.
Correct Answer: A

Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.

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The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique?

  • A. Remove old dressing using clean gloves. Discard gloves with old dressing
  • B. Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area
  • C. Apply sterile gauze dressing to wound area
  • D. Secure dressing with tape
Correct Answer: A

Rationale: The correct order ensures proper aseptic technique and wound care to prevent infection. The first step is to remove the old dressing using clean gloves to prevent contamination. Discarding the gloves with the old dressing helps maintain cleanliness. Choices B, C, and D are incorrect because cleaning the wound, applying a new dressing, and securing it should come after removing the old dressing to maintain asepsis and prevent infection.

What nursing intervention is particularly indicated for the second stage of labor?

  • A. Providing pain medication to increase the client's tolerance of labor
  • B. Assessing the fetal heart rate and pattern for signs of fetal distress
  • C. Monitoring effects of oxytocin administration to help achieve cervical dilation
  • D. Assisting the client to push effectively so that the expulsion of the fetus can be achieved
Correct Answer: D

Rationale: During the second stage of labor, assisting the client to push effectively is crucial for the delivery of the fetus. This action helps to facilitate the expulsion of the fetus from the uterus. Providing pain medication (Choice A) is not typically done during the second stage of labor as the focus shifts to pushing and delivery. Assessing the fetal heart rate (Choice B) is important but is more relevant throughout labor, not specifically for the second stage. Monitoring the effects of oxytocin administration (Choice C) is more associated with the first stage of labor to help with uterine contractions and cervical dilation.

In the Emergency Department, a female client discloses that she was raped last night. Which question is most important for the nurse to ask?

  • A. Does she know the person who raped her?
  • B. Has she taken a bath since the rape occurred?
  • C. Is the place where she lives a safe place?
  • D. Did she report the rape to the police department?
Correct Answer: A

Rationale: The most important question for the nurse to ask in this situation is whether the client knows the person who raped her. This question is crucial for assessing additional safety concerns, providing appropriate support, and determining the need for forensic evidence collection. Choices B, C, and D are not as critical in the immediate assessment and response to a rape victim. Asking about bathing, the safety of her home, or reporting to the police may be important but are secondary to identifying the perpetrator for safety and legal reasons.

The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

  • A. Vastus lateralis
  • B. Deltoid
  • C. Ventrogluteal
  • D. Dorsogluteal
Correct Answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to their limited muscle mass and safety. Infants do not have well-developed muscle mass, making the vastus lateralis the best option for IM injections. The deltoid muscle is typically used for older children and adults. Ventrogluteal and dorsogluteal sites are not recommended for infants due to safety concerns, including the risk of damaging the sciatic nerve. Therefore, the correct choice is the vastus lateralis for IM injections in infants.

The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider?

  • A. The appearance of the returning dialysate fluid is cloudy
  • B. The client complains of slight shortness of breath during installation
  • C. The amount of the returning dialysate fluid is greater than the amount instilled
  • D. The client complains of abdominal fullness and cramping during instillation
Correct Answer: A

Rationale: Cloudy dialysate fluid can indicate peritonitis, a serious complication of peritoneal dialysis. Peritonitis is an urgent condition that requires immediate evaluation and treatment. Reporting this finding promptly is crucial to prevent further complications. Choices B, C, and D are not indicative of peritonitis and do not require immediate reporting to the healthcare provider. Complaining of slight shortness of breath, having a greater return volume, and experiencing abdominal fullness and cramping are common occurrences during peritoneal dialysis and do not necessarily indicate an emergent issue.

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