HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
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?
Correct Answer: D
Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis.
Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure.
Choice B is incorrect as a GCS of 3 signifies a grave neurological status.
Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.
Question 2 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 highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (
Choice
B) is important but not the highest priority at this moment. Timing and recording uterine contractions (
Choice
C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (
Choice
D) is important but ensuring immediate safety takes precedence in this situation.
Question 3 of 5
A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action the nurse should take first is to refer the client to a healthcare provider for a pelvic examination. This is important to rule out serious conditions that may be causing the abdominal pain and dysmenorrhea. While notifying the parents, determining the date of the client's last menstrual period, and asking the client to lie down for a pelvic examination could be necessary steps, the priority is to ensure a proper evaluation by a healthcare provider to address the client's presenting symptoms effectively.
Question 4 of 5
When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C: Select a large, deep muscle mass. When administering an intramuscular injection with a painful medication volume of 3 ml, selecting a large and deep muscle mass is crucial. This intervention reduces discomfort for the patient and ensures proper absorption of the medication.
Choice A is incorrect because instilling the medication quickly can increase discomfort.
Choice B is incorrect as inserting the needle slowly may prolong the discomfort.
Choice D is incorrect as using a short, small gauge needle may not be suitable for delivering 3 ml of medication effectively into the muscle.
Question 5 of 5
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
Correct Answer: A
Rationale: The correct calculation for infusion based on the given data is 5 ml/hr.
To calculate the infusion rate per hour, you need to determine the number of contractions per hour. If contractions are occurring every 2-3 minutes, this would mean approximately 20-30 contractions per hour.
Therefore, if the pump is infusing 5 ml per contraction, the total infusion rate per hour would be 5 ml x 20 contractions = 100 ml/hr. This makes choice A the correct answer.
Choices B, C, and D are incorrect as they do not align with the calculation based on the given data.