HESI RN CAT Exam Quizlet

Correct Answer: A

Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.

Correct Answer: D

Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.

Correct Answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

Correct Answer: A

Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.

Correct Answer: A

Rationale: Administering the prescribed analgesic when requested reflects the nurse's value of client autonomy over veracity. This choice respects the client's right to manage their pain as they see fit. Enrolling the client in a substance abuse program (Choice B) assumes substance abuse without evidence and infringes on the client's autonomy. Providing a placebo (Choice C) violates the principle of beneficence and autonomy by deceiving the client. Documenting the frequency of medication requests (Choice D) is important for assessment but does not directly address the client's autonomy in managing their pain.