HESI RN
HESI RN CAT Exam Quizlet Questions
Question 1 of 5
A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention?
Correct Answer: B
Rationale: In a client with a C-6 spinal injury exhibiting shallow respirations and dyspnea, these signs could indicate respiratory compromise and potential respiratory failure. Intubation with an endotracheal tube may be necessary to secure the airway and support adequate oxygenation. Placing the client in reverse Trendelenburg position, administering pain medication, or instructing on deep breathing exercises would not directly address the urgency of the respiratory distress in this situation, making them incorrect choices.
Question 2 of 5
A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?
Correct Answer: D
Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.
Question 3 of 5
The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor?
Correct Answer: A
Rationale: In the context of postoperative thyroid surgery, monitoring calcium levels is crucial due to the proximity of the parathyroid glands to the thyroid. The parathyroid glands regulate calcium levels in the body, and damage during thyroid surgery can lead to hypocalcemia, a common complication. Symptoms of hypocalcemia include muscle cramps, tingling sensations, and even seizures, which can be life-threatening. Therefore, monitoring calcium levels is essential to detect and manage hypocalcemia promptly. Regarding the other options: - Monitoring sodium levels is important in various conditions, but it is not the most critical value to monitor in the immediate postoperative period following thyroid surgery. - Chloride levels are typically monitored in conditions like dehydration or metabolic alkalosis, but they are not the top priority after thyroid surgery. - Potassium levels are important to monitor, especially in patients on certain medications or with kidney issues, but they are not the most crucial value to assess on the first postoperative day after thyroid surgery. Educationally, understanding the specific implications of thyroid surgery on calcium regulation reinforces the importance of assessing and managing potential complications in surgical patients. This knowledge equips nurses to provide safe and effective postoperative care, emphasizing the significance of close monitoring and prompt intervention to prevent adverse outcomes.
Question 4 of 5
Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?
Correct Answer: A
Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.
Question 5 of 5
Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement?
Correct Answer: B
Rationale: The best action for the nurse-manager to implement is to propose a method for self-staffing labor and delivery. This approach allows nurses to manage their schedules, ensuring a fair balance of workloads. Requiring cross-training for obstetrics for other nurses (Choice A) may not be feasible or necessary for all units. Reminding nurses that floating is an administrative policy (Choice C) does not address the underlying issue of workload balance. Encouraging nurses to share their feelings with administration (Choice D) may not lead to a concrete solution for the unequal floating concerns.