HESI RN CAT Exit Exam 1

Correct Answer: C

Rationale: The correct action for the nurse to take when a client on ciprofloxacin reports loss of appetite and a metallic taste in the mouth is to notify the healthcare provider of the client's symptoms. These symptoms could indicate a need for a change in medication or additional treatment, which the healthcare provider would need to assess. Instructing the client to take ciprofloxacin with food (choice B) may help with gastrointestinal upset but will not address the reported symptoms. Reassuring the client (choice A) is important for providing emotional support but does not address the need for further evaluation. Encouraging increased fluid intake (choice D) is generally beneficial but may not directly address the specific side effects reported.

Correct Answer: B

Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.

Correct Answer: A

Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.

Correct Answer: B

Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (Choice A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (Choice C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (Choice D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.

Correct Answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.