which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication
Logo

Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication?

Correct answer: C

Rationale: The correct answer is C, complaints of shortness of breath on exertion. This symptom is indicative of heart failure, a common cardiac complication of arterial hypertension. Shortness of breath on exertion is often due to the heart's inability to pump effectively, leading to fluid buildup in the lungs. Choices A, B, and D are incorrect because complaints of an occipital headache, a palpable dorsal pedis pulse bilaterally, and a blood pressure of 160/90 do not specifically indicate a cardiac complication in a client with arterial hypertension.

2. 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?

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.

3. 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?

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.

4. Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?

Correct answer: C

Rationale: The correct answer is C. Clients in renal failure are at high risk for hypomagnesemia due to their impaired kidney function. Renal failure can lead to decreased excretion of magnesium, resulting in its buildup in the body and potential hypomagnesemia. This client requires careful nursing assessment for signs and symptoms of hypomagnesemia to prevent complications. Choices A, B, and D are not as directly associated with renal failure and its impact on magnesium levels. Intractable vomiting, hyperparathyroidism, and excessive consumption of simple carbohydrates may have other health implications but are not as strongly linked to hypomagnesemia as renal failure.

5. A client with a history of heart failure is admitted to the hospital with worsening dyspnea. The nurse notes that the client has a productive cough with pink, frothy sputum. What action should the nurse take first?

Correct answer: A

Rationale: In a client with heart failure presenting with worsening dyspnea and pink, frothy sputum (indicating pulmonary edema), the priority action for the nurse is to administer oxygen. Oxygen therapy helps improve oxygenation and alleviate dyspnea by increasing the oxygen supply to the lungs. Performing chest physiotherapy, elevating the head of the bed, or obtaining a sputum specimen are not the initial actions indicated in this situation and may delay addressing the client's immediate need for improved oxygenation.

Similar Questions

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?
One hour after delivery, the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first?
A male client tells the nurse, 'I am so stressed because I am expected to achieve excellence in everything. My job, my marriage, and my children must be perfect!' Which coping response should the nurse recognize that the client is using?
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses