HESI CAT Exam

HESI CAT Exam Related

Review HESI CAT Exam related questions and content

The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?

  • A. Perform a complete neurological examination
  • B. Measure the child's head circumference
  • C. Check the child's blood glucose level
  • D. Notify the healthcare provider immediately
Correct Answer: D

Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment.

Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected.

Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation.

Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.

You may also like to solve these questions

A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2 °F, and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

  • A. Occult blood in the stool
  • B. Abdominal distention
  • C. Elevated urine specific gravity
  • D. Hyperactive bowel sounds
Correct Answer: C

Rationale: Elevated urine specific gravity indicates concentrated urine, a sign of dehydration. In this scenario, the child is showing signs of dehydration with increased stool frequency, liquid consistency, fever, and vomiting. Occult blood in the stool may indicate gastrointestinal bleeding but is not a specific sign of dehydration. Abdominal distention can be seen in various conditions and is not a specific indicator of dehydration. Hyperactive bowel sounds can be present in various gastrointestinal conditions but are not directly related to dehydration.

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 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.

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.

A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only)

  • A. 2
  • B. 3
  • C. 4
  • D. 5
Correct Answer: A

Rationale: To calculate the maximum dosage in mg that the nurse should administer, multiply the dose per administration (0.4 mg) by the maximum number of doses allowed (5 doses): 0.4 mg/dose * 5 doses = 2 mg. Therefore, the nurse should administer a maximum dosage of 2 mg to the client. Choices B, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

Copyright © 2025 Nokea. All rights reserved.