HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Lower the oxygen rate. Increasing oxygen flow too quickly can lead to oxygen toxicity in COPD patients, causing symptoms like lethargy and confusion. Lowering the oxygen rate will help alleviate the symptoms and prevent further harm. Repositioning the nasal cannula (choice
A) is not the priority in this situation. Encouraging coughing and deep breathing (choice
C) may not address the immediate issue of oxygen toxicity. Monitoring oxygen saturation (choice
D) is important but should follow lowering the oxygen rate to address the current symptoms.
Question 2 of 5
A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?
Correct Answer: B
Rationale: The correct answer is B: Ineffective breathing pattern. In late-stage ALS, respiratory muscles weaken, leading to breathing difficulties. Priority is given to maintaining adequate oxygenation and ventilation. Impaired physical mobility (choice
A) is important but not the highest priority. Impaired skin integrity (choice
C) and risk for infection (choice
D) may result from immobility but are secondary to the critical issue of breathing in this scenario.
Question 3 of 5
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
Correct Answer: A
Rationale: The correct answer is A because raising the side rails and placing the call bell within reach ensures the safety and immediate accessibility of the client, which is the highest priority in nursing care. This intervention helps prevent falls or other accidents and allows the client to call for assistance if needed.
Choice B is incorrect because teaching pushing techniques is important but not the highest priority at this moment.
Choice C, timing and recording uterine contractions, is also important but not the highest priority compared to ensuring the client's safety.
Choice D, positioning for anesthesia distribution, is relevant but not as critical as ensuring immediate access to assistance in case of emergency.
Question 4 of 5
In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
Correct Answer: C
Rationale: The correct action is to administer the dose of furosemide as scheduled (
Choice
C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (
Choice
D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (
Choice
A) is important but not the immediate priority in this situation. Administering nitroglycerin (
Choice
B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.
Question 5 of 5
A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention.
A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder.
C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying.
D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.