Cat exam 1- 4 Hesi Exit 2022/2023 Quiz Bank with complete solution
CAT 1
1. A client is comatose upon arrival to the emergency department after falling
... [Show More] a roof. The
client flexes with painful stimuli, and the nurse determines the client’s Glasgow Coma
Scale (GCS) is 6. Which intervention should the nurse prepare to implement to maintain
the client’s airway?
A. An endotracheal tube
B. A nasopharyngeal tube
C. An oral airway
D. Tracheostomy tube insertion
2. A client is receiving a continuous half strength tube feeding at 50 ml/hr. To prepare
enough of the solution for eight hours, how many ml of full strength feeding will the
nurse need?
Answer: 200
25 ml x 8hrs = 200
3. The alarm of a client’s pulse oximeter sounds and the nurse notes that the oxygen
saturation rate is indicated at 85%. What action should the nurse take first?
A. Administer oxygen by face mask
B. Notify the healthcare provider
C. Reset the alarm
D. Check the probe position
4. A client is known to have an irregular respiratory rate with periods of apnea lasting 10 to
15 seconds. Currently, the nurse counts 22 respiratory cycles in a 30-second interval
followed by an apneic period. What intervention should the nurse implement?
A. Reassess the respiratory rate, counting for one full minute
B. Call a code and initiate cardiopulmonary resuscitation
C. Immediately place the client in Trendelenburg position
D. Record the respiratory rate and notify the respiratory therapist
5. A retiree with depression complains of feeling “lonely and having no purpose” in life.
Based on Erikson’s developmental theory, which questions suggest that the nurse
understands the client’s most important emotional need?
A. “Where can you go to be with others?”
B. “What about your life makes you proud?”
C. “How do you spend your days?”
D. “What time of the day do you feel lonely?”
6. Following a precipitous labor, a client has a continuous trickling of bright red blood from
her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse
determines that the client’s symptoms may indicate which condition?
A. A cervical laceration
B. A normal fourth stage of labor
C. Early postpartum hemorrhage
D. Inadequate uterine contractions
7. In preparing assignments for the shift, which client is best for the charge nurse to assign
to a practical nurse?
A. An older client who fell yesterday and is now complaining of diplopia
B. An adult newly diagnosed with type 1 diabetes and high cholesterol
C. A client with pancreatic cancer who is experiencing intractable pain
D. An elderly client with Alzheimer’s disease complicated by dysphagia
8. The healthcare provider prescribes oxygen per nasal cannula at 2 L/min. Which action
has the highest priority when the nurse implements this prescription?
A. Set the flow meter
B. Administer oral care
C. Pad bony prominences
D. Apply a humidifier
9. A nurse who is new to the pediatric unit is positioning a 6-month-old for an injection of
penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager
who is supervising this nurse take first?
A. Review the correct landmarks before the site is injected
B. Explain the correct procedure for giving the medication
C. Instruct the nurse to select another injection site
D. Demonstrate techniques for restraining the infant
10. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse
provides home care instructions to the mother. Which statement by the child’s mother
indicates that she understands home care treatment to promote pulmonary function?
A. “Cough suppressants can be used four times a day”
B. “The oxygen should be kept at 4 to 6 L/min”
C. “Chest physiotherapy should be performed at least twice a day”
D. “Activities should be planned to avoid physical exertion”
11. The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation?
A. Encourage intake of foods high in vitamin E
B. Decrease intake of foods high in fat
C. Decrease heavy lifting and bending
D. Encourage physical activity
12. The nurse reviews the signs of hypoglycemia with the parents of a child with Type 1
diabetes mellitus. The parents correctly understands signs of hypoglycemia if they
include which symptom?
A. Sweating
B. Increased urination
C. Fruity breath odor
D. Thirst
13. The nurse observes a 2 cm area nonblanchable erythema on the sacrum of an immobile
client. What documentation of this finding is best for the nurse to enter into the client’s
record?
A. Sacral area red and inflamed
B. 2 cm area reactive hyperthermia on sacrum
C. Stage 1 pressure ulcer on sacrum
D. Client at high risk for pressure ulcer
14. When assessing a 7-year-old girl, the nurse notes that she has multiple bruises on her
back and upper arms. The child’s aunt tells the nurse that the child’s parents abuse
drugs and alcohol. What intervention is most essential for the nurse to implement?
A. Notify child’s healthcare provider of the assessment findings
B. Determine the reliability of the aunt’s report
C. Report the child’s condition to the nursing supervisor
D. Report assessment findings to the proper legal authorities
15. A 14-year-old male client arrives at the emergency room in status epilepticus. He was
diagnosed with a seizure disorder in childhood. What is the most likely cause of his
present condition?
A. Increasing intracranial pressure
B. Acute withdrawal from anticonvulsant medication
C. A closed head injury
D. A central nervous system infection
16. A Chinese-American client who just delivered a baby states that she will not be able to
take the prescribed sitz baths to help heal her episiotomy incision because this will
cause an unhealthy balance of cold and hot forces. When planning nursing care, what
nursing diagnosis has the highest priority?
A. Knowledge deficit related to healing process
B. Noncompliance related to cultural diversity
C. Anxiety related to cultural diversity
D. Impaired tissue integrity related to episiotomy
17. A 2-year-old with sickle cell anemia has an axillary temperature of 102 F. In planning
care for this child, which nursing diagnosis has the highest priority?
A. High risk infection related to low platelet count
B. High risk for fluid volume deficit related to temperature elevation
C. Alteration in urinary elimination related to renal damage from disease
D. Potential activity intolerance related to anemia
18. During the first trimester of pregnancy, a client who was treated for genital herpes
with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is experiencing
an episode of genital herpes. Which nursing intervention has the highest priority?
A. Identify current sexual partners so that they can be evaluated and treated for genital
herpes if necessary
B. Determine if the client has taken acyclovir (Zovirax) for this outbreak of genital herpes
C. Instruct her to avoid sexual intercourse while active, visible lesions are present
D. Assess her feelings about therapeutic abortions in the event the infant has been affected
19. The nurse is obtaining a medication history for a client with a new prescription for
paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid
(Marplan). What intervention is most important for the nurse to implement?
A. Instruct the client to use good oral hygiene measures to reduce dry mouth
B. Assess the client for an increased sense of well-being once started on the Paxil
C. Instruct the client to avoid foods high in tyamine while taking Marplan
D. Notify the healthcare provider that the client is currently taking Marplan
20. While performing a skin inspection on a newborn, the nurse finds a small dimple and a
dark tuft of hair in the lumbosacral area of the infant’s back. What is the most likely
indication of this finding?
A. External manifestation of a spinal abnormality
B. Expected finding in a newborn
C. Uncommon but normal variation in newborns
D. Variation often seen in dark-skinned infants
21. What action should the nurse implement first when delegating nursing activities to an
unlicensed assistive personnel (UAP)?
A. Consider the client’s ability to assist the UAP
B. Evaluate the experience of the UAP
C. Prioritize each assigned client’s needs
D. Determine if family is available to help
22. A female resident of a long-term care facility is being admitted to the medical
department. The client has a fractured hip and has methicillin-resistant staphylococcus
aureus (MRSA). Which room should the charge nurse assign this client?
A. A semi-private room with a client who also has methicillin-resistant staphylococcus
aureus (MRSA)
B. A private room, and institute blood-borne standard precautions
C. A semi-private room with a client who has enterococci resistant to vancomycin (VRE)
D. A private isolation room with a vented negative airflow system
23. The nurse is preparing a client for surgery. Which finding indicates that the client is
ready to proceed to the operating room (OR) for a scheduled surgical procedure?
A. Hemoglobin 10.1 grams
B. Client questions which surgery is scheduled
C. Clopidogrel (Plavix) received yesterday
D. INR results of 3.1
24. The nurse is preparing to administer an intramuscular injection in the ventrogluteal site
of a client who weighs 80 kg. What size needle should the nurse select?
A. 25-gauge, 1-inch needle
B. 27-gauge, 5/8-inch needle
C. 21-gauge, 1.5-inch needle
D. 20-gauge, 3-inch needle
25. A client at 38-weeks gestation is in active labor, and a vaginal birth after Cesarean
section (VBAC) is planned. Vaginal exam indicates that the client is 6 cm dilated, 90%
effaced, and at station 0 with intact membranes. As the client’s contraction become
stronger, the fetal heart rate decelerates during the contractions but returns to
baseline. What action should the nurse take?
A. Prepare for an emergency Cesarean delivery
B. Set up an amniotomy tray
C. Continue to monitor the client’s labor progress
D. Apply a fetal scalp electrode
26. An elderly client with limited mobility reports frequent episodes of nocturia. To reduce
the risk for urinary incontinence, what action should the nurse implement?
A. Maintain a calm and quiet environment
B. Review the client’s serum creatinine level
C. Obtain a prescription for a hypnotic at bedtime
D. Keep the call bell within the client’s reach
27. Which diagnostic tests are most important for the nurse to monitor when providing
care for a client with a bowel obstruction?
A. Serum albumin and protein
B. Serum liver enzymes
C. Serum electrolytes
D. Gastric pH analysis
28. A 72-year-old male client reports that he has felt depressed since his wife died six
months ago. What question is most important for the nurse to ask this client?
A. “Have you ever had a loved one die before?”
B. “Do you have close friends in whom you can confide?”
C. “Are you sleeping and eating well?”
D. “Have you ever felt like hurting yourself?”
29. After administering the first dose of newly prescribed to four clients within a thirty
minute time frame, the nurse evaluates each client for therapeutic responses or any
adverse reactions. Which medication should the nurse evaluate first?
A. Clopidrogel (Plavix)
B. Nystatin (Mycostatin)
C. Enoxaparin (Lovenox)
D. HYdromorphone (Dilaudid)
30. What is the most important symptom the nurse should monitor the client for while
assisting with the insertion of a subclavian central venous catheter?
A. Edema at the insertion site
B. Paralysis of the face and neck on the side of insertion
C. Pain, accompanied by nausea and vomiting
D. Shortness of breath
31. The nurse is developing a plan of care for a client who has a prescription for the
calcium channel-blocker nifedipine (Procardia) to treat angina pectoris. What is the
purpose for administration of this medication?
A. Increase heart rate and force of contraction
B. Reduce the incidence of clot formation
C. Stimulate the vagus nerve to increase heart rate
D. Decrease myocardial oxygen demands
32. While transcribing a new prescription, the nurse notes that the prescribed dosage is
much lower than the recommended dosage listed in the drug reference guide. Which
client data supports this dosage reduction?
A. Increasedserum protein
B. Increased liver enzymes
C. Decreased serum creatinine
D. Prolonged prothrombin time
33. The nurse notes that a postoperative adult client’s respiratory rate is 10
breaths/minute. Which factor in the client’s history is the most likely explanation for
this finding?
A. Postoperative laboratory test results indicate that the client’s hemoglobin is 10.1 gm/dl
and hematocrit is 30.4%
B. The client has a ten-year history of chronic obstructive pulmonary disease (COPD)
C. The PCA pump containing morphine sulfate was discontinued 15 minutes before vital
signs were taken
D. The client smoked one pack of cigarettes/day for the past 20 years, before quitting
smoking 30 days ago
34. The charge nurse working on a postpartum unit is making assignments for a staff
consisting of a registered nurse (RN), a practical nurse (PN), and two unlicensed
assistive personnel (UAP). Which client should the charge nurse assign to the registered
nurse?
A. A primigravida who delivered an infant 6 hours ago via vaginal delivery and is now
complaining of seeing spots
B. A multigravida who is breastfeeding her infant and is preparing for discharge with her
infant
C. A client who delivered a 10 pound infant 8 hours ago via cesarean section and is now
complaining of pain
D. A client who had an epidural for a vaginal delivery one hour ago and now needs assistance
to the bathroom
35. A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted
with osteomyelitis. The healthcare provider collects bone aspirate specimens for
culture and sensitivity and applies a cast to the adolescent’s lower leg. What action
should the nurse implement next?
A. Provide a high-calorie, high-protein diet
B. Initiate parenteral antibiotic therapy
C. Administer antiemetic agents
D. Encourage partial weight-bearing
36. A child with heart is receiving the diuretic furosemide (Lasix) and has a serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to
obtain?
A. Dietary intake of potassium rich foods
B. Skin turgor
C. Heart rate and cardiac rhythm
D. Urinary output
37. It is determined that a client with breast cancer has metastasis to the liver. What is the
most likely explanation for the client’s risk of developing hemorrhagic tendencies?
A. The inability of the liver to synthesize clotting factors
B. The presence of a lowered red blood cell count
C. The loss of clotting factors resulting from chemotherapy
D. The loss of serum proteins found in edematous fluid
38. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of
fluid are removed. Which assessment parameter is most critical for the nurse to
monitor following the procedure?
A. Pedal pulses
B. Breath sounds
C. Vital signs
D. Gag reflex
CAT 2
1. A client with a hemothorax has a chest tube in the fourth intercostal space connected to
suction at 20 cm H2O pressure. Four hours after insertion, which client outcome should
the nurse consider to be within normal limits for this client?
A. No bubbling in the suction chamber of the Pleuravac
B. Serous fluid in the drainage chamber of the Pleurovac
C. Fluctuation with respiration in the water-seal chamber of the Pleuravac
D. The dry gauze dressing over the insertion site is clean and intact
2. A client has started long-term maintenance therapy with a cardiotonic medication that
has a narrow therapeutic index. Teaching the client the signs/symptoms of which adverse
effect is most important?
A. Displacement
B. Toxicity
C. Dependence
D. Tolerance
3. In caring for a client who is receiving peritoneal dialysis, the nurse should be alert for
that what complications?
A. Clear dialysate drainage and burning on urination
B. An occluded vascular access device and flank pain
C. Abdominal pain, tenderness, and rigidity
D. Increased serum albumin level, decreased BUN, and increase hematocrit
4. A high fluid intake is prescribed for a client with urolithiasis. The client wishes to know
the chief purpose for this intervention. What should the nurse tell the client about this
prescription?
A. This action is designed to decrease the uric acid in the urine
B. The purpose is to increase the hydrostatic pressure behind the stone to assist in its
downward passage
C. The intent is to increase the specific gravity of the urine, thereby increasing the probability
of passing the stone
D. The fluids will increase bilirubin excretion, thereby assisting to resolve jaundice associated
with stone formation
5. Normal saline 0.9% is prescribed for a client with fluid volume deficit at a rate of 100
ml/hour. Before starting the infusion, the nurse observes that the client’s urine is dark
amber in color. What action should the nurse take?
A. Start the IV at a keep-open rate until the assessment finding is reported o the healthcare
provider
B. Insert a saline lock, but do not start any IV fluid until contacting the healthcare provider
C. Review the list of PRN medications to see if a diuretic can be administered
D. Administer the normal saline at the prescribed rate of 100 ml/hour
6. Which explanation of autonomic cardiac regulation mediated by sympathetic
innervations is correct?
A. Sympathetic activation boosts K+ efflux and increases the inotropic effect
B. Increased Ca+ influx with sympathetic stimulation raises the heart rate
C. Sympathetic activation decreases dromotrophy by lowering conduction speed
D. Increased Na+ influx with sympathetic stimulation reduces pacemaker firing
7. The nurse learns that a newly admitted adult client has a six month history of recurring
somatic pain. During the admission interview, it is most important for the nurse to
question the client about what problem?
A. Periods of restlessness
B. Episodes of tremors
C. Feelings of depression
D. Nausea and vomiting
8. A pregnant client begins to cry when the UAP tries to assist her in donning a hospital
gown, and she refuses to remove an undergarment that is worn in her culture to preserve
modesty. What should the charge nurse do first?
A. Incorporate individualized cultural care into the nursing plan of care
B. Discuss the importance of respecting cultural beliefs with the UAP
C. Determine if continued wearing of the garment will compromise care
D. Talk with the client to determine alternate means to preserve modesty
9. The nurse is preparing to insert an IV in an adult male client. Which client’s lab value is
most important for the nurse to consider prior to inserting the IV?
A. Serum sodium of 130 mEq/L
B. WBC of 12,000/mm
C. Hemoglobin of 12 g/dl
D. Platelet count of 60,000/mm
10. A 12-year-old boy who is 54 inches tall is scheduled for x-rays of his hands and wrist to
determine growth patterns. The mother asks the nurse why these x-rays are being taken.
What explanation is best for the nurse to provide this mother?
A. If the growth areas of the bone are closed, then growth hormone therapy can open them
B. Hormonal influences on the bone at this age can be determined by x-ray
C. Wrist and hand fractures are common among children of small stature
D. X-ray therapy is helpful in promoting the effectiveness of growth hormone therapy
CAT 3
1. An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder
arrives in an elated state. What is the best room assignment the nurse can make for this client?
a. A quiet room away from the nurse’s station.
b. A bright-colored room located near the recreation room.
c. A room that contains very little furniture.
d. A room that has at least two other clients assigned to it.
2.The community mental health nurse is planning to visit four clients with schizophrenia. Which
client should the nurse see first?
a. A mother who took her children from school because aliens were after them.
b. A young man who has a history of substance abuse and had no telephone.
c. A newly diagnosed client who needs to be evaluated for medication compliance.
d. A young man recently released from prison who requires an intake assessment.
3.A female client, the mother of two small children, appears depressed after learning from her
healthcare provider that she has multiple sclerosis. Which nursing intervention should the nurse
implement first?
a. Provide the client with information about the Multiple Sclerosis Society.
b. Leave the room so the client has privacy to grieve.
c. Encourage the family to be available to the client as much as possible.
d. Sit quietly with the client and answer questions she may ask.
4.Which statement by a client with emphysema indicates the best understanding of the purpose
of pulmonary function testing?
a. “I won’t pass the test because I smoke and have emphysema.”
b. “It will measure how well my lungs are working.”
c. “I’m afraid I’ll find out that I have lung cancer.”
d. “This test measures how much oxygen I have in my lungs.”
5. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of
psychosocial development, which nursing intervention best assists this adolescent’s adjustment
to his hospital stay?
a. Invite him to participate in the evening group activity.
b. Schedule frequent private phone calls to his parents.
c. Provide access to a variety of video games in his room.
d. Encourage him to learn his way around the hospital.
6. Which individual may legally sign an informed consent?
a. A 16-year-old mother for her newborn.
b. The friend of an 84-year-old married client.
c. A 56-year-old who questions a proposed treatment plan.
d. A 42-year-old client who is sedated.
7. The nurse working on a psychiatric unit is concerned about providing ethical and legally
defensible care for clients on the unit. Which occurrence is an indication that a client’s civil rights
are being violated? A client who
a. attempted suicide recently is not allowed to wear a belt or have shoelaces.
b. made threatening phone calls is allowed to make phone calls only under the supervision of
a staff member.
c. refused to take an oral psychiatric medication is administered the same medication as an
IM injection.
d. is anorexic is not allowed to go to the bathroom after meals unless accompanied by a staff
member.
8. Which statement by the mother of a toddler girl indicates to the nurse that scheduled vaccine
should not be administered?
a. “Her throat closed up so bad shecouldn’t breathe the last time she got this shot.”
b. “My child has been running a little fever and has a runny nose and cough.”
c. “Her baby brother has a virus and has had diarrhea for three days now.”
d. “Her arm gets all red and hurts a lot every time she gets a vaccination.”
9. Thirty-six hours after delivery, the nurse assesses a client’s fundus just above the umbilicus
and displaced to the right of the midline. What actions should the nurse take first?
a. Palpate the bladder for distention.
b. Assess the amount of lochia.
c. Ask the client when her last bowel movement occurred.
d. Catheterize the client and record the amount.
10. A hospitalized 81-year-old female client has numerous complaints and uses her call button
often to summon staff to help her with activities that she is capable of performing for herself.
Which plan might be most beneficial in dealing with this client?
CAT 4
1. A 59-year-old male client is brought to the emergency room where he is assessed to
have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse
characterize the client’s condition?
a. The client has increased intracranial pressure
b. He has a good prognosis for recovery
c. This client is conscious, but is not oriented to time and place
d. He is in a coma, and has a very poor prognosis
2. At a community health fair, a 50-year-old woman tells the nurse that she has an
annual physical exam that includes a clinical breast exam and an annual mammogram.
How should the nurse respond?
a.
Encourage the woman to explore her fears about breast cancer.
b.
Ask the woman if she also performs monthly breast self- exams.
c.
Commend the woman for adhering to the recommended cancer detection guidelines.
d.
Advise the woman that mammograms are only needed every two years at her age.
3. Which assessment finding should indicate to the nurse that a client with arterial
hypertension is experiencing a cardiac complication?
a. Complaints of an occipital headache
b. A palpable dorsal is pedis pulse bilaterally
c. Complaints of shortness of breath on exertion
d. A blood pressure of 160/90
4. A college student who is diagnosed with a vaginal infection and vulva irritation
describes the vaginal discharge as having a “cottage cheese” appearance. Which
prescription should the nurse implement first?
a. Cleanse perineum with warm soapy water 3 times per day
b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
c. Perform glucose measurement using a capillary blood sample
d. Obtain a blood specimen for sexually transmitted disease (STDs)
5. A client in acute renal failure has 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 insulsubcutaneously.
b. Administer a retention enema of Kayexalate
c. Add 40 mEq of KCL(potassium chloride) to present IV solution.
d. Administer a lidocaine bolus IV push.
6. A client who had an intraosseous (IO) cannula placed by the healthcare provider for
an emergent fluid resuscitation is complaining of severe pain and numbness below
the IO sit. The skin around the site is pale and edematous. What actionshould the
nurse takes first?
a. Discontinue the IO infusion
b. Administer an analgesic via the IO site
c. Elevate the extremity with the IO site
d. Notify the healthcare provider
7. The nurse-manager of a perinatal unit is notified that one client from the medicalsurgical unit needs to be transferred to male room for new admissions. Which client
should the nurse recommend for transfer to the antepartal unit?
a. A 45-year-old who has a chronic hepatitis B.
b. A 35-year-old with lupus erythematous
c. A 19-year-old who is diagnosed with rubella
d. A 25-year-old with herpes lesions of the vulva
8. A nurse is teaching a client postoperative breathing techniques using an incentive
spirometer (IS). What should the nurse encourage this client to do to maintain
sustained maximal inspiration?
a. Breathe into the spirometer using normal breath volumes
b. Exhale forcefully into the tubing for 3 to 5 seconds
c. Inspire deeply and slowly over 3 to 5 seconds
d. Perform IS breathing exercises every 6 hours
9. The nurse plans to educate a client about the purpose for taking the prescribed
antipsychotic medication clozapine (Clozaril). Which statement should the nurse
provide?
a. You will be able to cope with your symptoms
b. It will help you function better in the community
c. The medication will help you think more clearly”
d. It will improve your grooming and hygiene
10. A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and
azithromycin (Zithromax) PO daily, using medication he brought from home. When
the nurse delivers hisbreakfast tray, the client tells the nurse that he took his
insulin but forgot to take his daily dose of the Zithromax an hour before breakfast
as instructed. What action should the nurse implement? [Show Less]