HESI RN CAT Exam Quizlet

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In attempting to develop a therapeutic relationship with a male adult client transferred to a psychiatric facility after being treated for a self-inflicted gunshot wound, which information is most important for the nurse to determine?

  • A. The family's reaction to this situation
  • B. The nurse's feelings about this client
  • C. What losses the client recently experienced
  • D. Why the client attempted to kill himself
Correct Answer: C

Rationale: Understanding what losses the client recently experienced is crucial for the nurse in developing a therapeutic relationship. This information helps the nurse comprehend the client's emotional state, the potential triggers for the self-harm behavior, and provides insights into the client's current psychological and social challenges. Choice A, the family's reaction, may be important but is secondary to understanding the client's own experiences. Choice B, the nurse's feelings, is not relevant as the focus should be on the client. Choice D, why the client attempted suicide, is important but delving into recent losses can provide a broader context for the client's emotional distress and suicidal behavior.

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A 9-year-old boy with tetralogy of Fallot is being discharged following a cardiac catheterization. Which discharge instruction should the nurse provide the parents?

  • A. Do not allow the child to return to school for at least one month
  • B. Notify the healthcare provider if there is any drainage at the catheterization site
  • C. Monitor the child's temperature and report any elevation
  • D. Observe for any changes in the child's color or energy level
Correct Answer: B

Rationale: The correct answer is to notify the healthcare provider if there is any drainage at the catheterization site. Drainage at the site can be a sign of infection, which needs prompt evaluation and treatment. Choices A, C, and D are not as crucial as identifying and reporting any drainage, which is more directly related to potential complications post-cardiac catheterization.

The nurse is assessing a client who has a new cast on the left arm. Which finding should the nurse report to the healthcare provider immediately?

  • A. Client reports itching under the cast
  • B. Client reports pain at the cast site
  • C. Client reports swelling of the fingers
  • D. Client reports warmth over the casted area
Correct Answer: C

Rationale: Swelling of the fingers can indicate compromised circulation, which is a serious concern in a client with a new cast. It could suggest the development of compartment syndrome, a condition where increased pressure within the muscles can lead to impaired blood flow. This can result in tissue damage and should be addressed promptly. Itching under the cast, pain at the cast site, and warmth over the casted area are common findings after cast application and may not necessarily indicate an urgent issue requiring immediate reporting to the healthcare provider.

A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?

  • A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
  • B. Administer a retention enema of Kayexalate.
  • C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
  • D. Administer a lidocaine bolus IV push.
Correct Answer: B

Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.

A nurse is planning care for a client who is at risk for developing deep vein thrombosis (DVT). Which intervention should the nurse include in this client's plan of care?

  • A. Maintain the client on bed rest
  • B. Apply warm, moist compresses to the legs
  • C. Encourage early ambulation
  • D. Massage the legs daily
Correct Answer: C

Rationale: The correct intervention for a client at risk for developing deep vein thrombosis (DVT) is to encourage early ambulation. Early ambulation helps prevent DVT by promoting circulation, reducing stasis, and preventing blood clot formation. Maintaining the client on bed rest (Choice A) would increase the risk of DVT due to decreased mobility. Applying warm, moist compresses to the legs (Choice B) can be beneficial for other conditions but does not directly prevent DVT. Massaging the legs daily (Choice D) can dislodge a blood clot, leading to serious complications in a client at risk for DVT.

While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?

  • A. Consuming a high-fat diet
  • B. Using tanning beds
  • C. Smoking cigarettes
  • D. Drinking alcohol
Correct Answer: B

Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.

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