HESI RN CAT Exit Exam 1

An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?

When obtaining an admission history for a client who is at 9 weeks gestation, the client states, 'I had a miscarriage 2 years ago.' Which information is most important for the nurse to obtain?

The nurse is preparing a client for discharge who has a prescription for enoxaparin (Lovenox) self-administration. What information is most important for the nurse to provide the client about this medication?

The nurse is planning care for a client with a stage III pressure ulcer. Which intervention is most important for the nurse to include in the plan of care?

The nurse is planning care for a 2-year-old child who is scheduled for an infusion of immune globulin for treatment of idiopathic thrombocytopenic purpura (ITP). Which nursing diagnosis has the highest priority for this child?