HESI RN
HESI RN CAT Exit Exam 1 Questions
Question 1 of 5
The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?
Correct Answer: A
Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.
Question 2 of 5
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?
Correct Answer: B
Rationale:
Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication.
Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses.
Choice A focuses on the client's behavior rather than the therapeutic effect of the injection.
Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation.
Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.
Question 3 of 5
A client who is taking ciprofloxacin (Cipro) reports to the nurse of having a loss of appetite and a metallic taste in the mouth. What action should the nurse implement?
Correct Answer: C
Rationale: The correct action for the nurse to take when a client on ciprofloxacin reports loss of appetite and a metallic taste in the mouth is to notify the healthcare provider of the client's symptoms. These symptoms could indicate a need for a change in medication or additional treatment, which the healthcare provider would need to assess. Instructing the client to take ciprofloxacin with food (choice
B) may help with gastrointestinal upset but will not address the reported symptoms. Reassuring the client (choice
A) is important for providing emotional support but does not address the need for further evaluation. Encouraging increased fluid intake (choice
D) is generally beneficial but may not directly address the specific side effects reported.
Question 4 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 5 of 5
The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?
Correct Answer: B
Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (
Choice
A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (
Choice
C) and implementing aspiration precautions (
Choice
D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.