HESI RN
HESI RN CAT Exit Exam 1 Questions
Question 1 of 5
A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?
Correct Answer: A
Rationale: Removing the client's peripheral IV access is essential before the client leaves against medical advice to prevent complications such as infection, thrombosis, or bleeding. Administering pain relief medication (choice
B) can be important but not essential at this point. Obtaining neurological vital signs (choice
C) is not specifically required before the client leaves. Providing the client with the hospital's phone number (choice
D) may be helpful but is not as essential as ensuring the safe removal of IV access.
Question 2 of 5
A client newly diagnosed with gastroesophageal reflux disease (GERD) is being taught about dietary management by a nurse. Which instruction should the nurse include?
Correct Answer: C
Rationale: The correct instruction for a client with GERD is to avoid eating spicy foods. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing stomach acid production. Avoiding spicy foods can help reduce discomfort and prevent further irritation.
Choices A, B, and D are incorrect. Drinking milk is not advised for GERD as it can trigger acid production. Eating three large meals a day can put pressure on the stomach, worsening symptoms. Increasing fluid intake with meals can lead to bloating and worsen GERD symptoms by causing the stomach to expand, pushing more acid into the esophagus.
Question 3 of 5
A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?
Correct Answer: C
Rationale: The correct response is to encourage the client to perform breast self-examination (BSE) 2 to 3 days after her menstrual period ends. This timing is important because breasts are least tender during this phase of the menstrual cycle, allowing for a more effective examination.
Choice A is incorrect because while scheduling an annual mammogram is important, the immediate concern is the timing of BSE.
Choice B is incorrect as the client's BSE practice just needs a slight adjustment in timing, not an in-depth review.
Choice D is incorrect as the client should perform BSE when her breasts are least tender for optimal detection of any abnormalities.
Question 4 of 5
A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?
Correct Answer: D
Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration.
Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis.
Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.
Question 5 of 5
A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
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.