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: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment.
Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
Question 2 of 5
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B: Instill the first dose of nystatin (Mycostatin) vaginally per applicator. This is the appropriate action for a college student with symptoms of a vaginal infection with a 'cottage cheese' appearance discharge, which is indicative of a yeast infection (most likely caused by Candida). Nystatin is an antifungal medication effective against Candida, hence addressing the root cause of the infection. It is essential to start with the treatment first to alleviate the symptoms and prevent further complications.
Incorrect choices:
A: Cleansing the perineum with warm soapy water may provide some comfort but does not address the underlying infection.
C: Performing a glucose measurement is not necessary at this stage as the symptoms suggest a yeast infection, not diabetes.
D: Obtaining a blood specimen for STDs is not the priority in this case as the symptoms are indicative of a yeast infection, not an STD.
Question 3 of 5
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
Correct Answer: B
Rationale: The correct answer is B: A 35-year-old with lupus erythematosus. This client should be recommended for transfer to the antepartal unit because lupus erythematosus is an autoimmune disorder that can affect pregnancy outcomes. The antepartal unit is better equipped to provide specialized care for high-risk pregnancies, which would be necessary for a client with lupus.
A: A 45-year-old with chronic hepatitis B - Hepatitis B does not directly impact pregnancy outcomes and does not require transfer to the antepartal unit.
C: A 19-year-old diagnosed with rubella - Rubella is a viral infection that can be harmful during pregnancy, but the client should be managed in a different unit specialized in infectious diseases.
D: A 25-year-old with herpes lesions of the vulva - Herpes lesions of the vulva can be managed in the medical-surgical unit and do not necessarily require transfer to the antepartal unit unless there
Question 4 of 5
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to eat his breakfast and take the Zithromax two hours after eating. This is the correct action because azithromycin is best absorbed when taken on an empty stomach, but if the client has already eaten, it is recommended to wait at least 2 hours after a meal before taking it. This ensures optimal absorption and effectiveness of the medication.
Choice A is incorrect because it does not address the timing issue of taking azithromycin on an empty stomach.
Choice C is incorrect as skipping a dose of an antibiotic can lead to treatment failure.
Choice D is incorrect as antacids can interfere with the absorption of azithromycin and should not be taken together.
Question 5 of 5
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
Correct Answer: D
Rationale: The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up.
A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned.
B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers.
C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension.
In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.