HESI RN
HESI RN CAT Exam Quizlet
1. The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?
- A. Bananas and pineapple
- B. Cottage cheese and crackers
- C. Peanut butter and jelly
- D. Tomato and lettuce salad
Correct answer: D
Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.
2. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
- A. 5
- B. 10
- C. 15
- D. 20
Correct answer: A
Rationale: The correct calculation for infusion based on the given data is 5 ml/hr. To calculate the infusion rate per hour, you need to determine the number of contractions per hour. If contractions are occurring every 2-3 minutes, this would mean approximately 20-30 contractions per hour. Therefore, if the pump is infusing 5 ml per contraction, the total infusion rate per hour would be 5 ml x 20 contractions = 100 ml/hr. This makes choice A the correct answer. Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.
3. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
- A. A 45-year-old with chronic hepatitis B.
- B. A 35-year-old with lupus erythematosus
- C. A 19-year-old diagnosed with rubella
- D. A 25-year-old with herpes lesions of the vulva
Correct answer: B
Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.
4. The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
- A. Activity tolerance as evidenced by appropriate age-level activities being performed
- B. Absence of skin breakdown as evidenced by intact skin and absence of redness
- C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
- D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr
Correct answer: D
Rationale: In acute glomerulonephritis, maintaining fluid balance is the priority to prevent complications like fluid overload or dehydration. Monitoring urine output within the range of 1 to 2 ml/kg/hr is crucial in assessing renal function. While activity tolerance, skin integrity, and nutritional status are important aspects of care, fluid balance takes precedence due to its direct impact on the renal condition and overall health outcome for the child.
5. The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
- A. Blood glucose of 140 mg/dL
- B. White blood cell count of 8000/mm³
- C. Serum potassium of 3.8 mEq/L
- D. Serum calcium of 7.8 mg/dL
Correct answer: D
Rationale: The correct answer is D. A serum calcium level of 7.8 mg/dL requires immediate intervention due to the risk of hypocalcemia. Hypocalcemia can lead to serious complications such as tetany, seizures, and cardiac arrhythmias. The other laboratory findings are within normal limits or slightly elevated, which do not pose an immediate threat to the client's health in this scenario.
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