HESI RN
HESI RN CAT Exit Exam Questions
Question 1 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: Rationale: 1. Pelvic pain and dysmenorrhea could indicate gynecological issues. 2. Referring the client for a pelvic exam allows for a thorough assessment. 3. It helps identify any underlying conditions or infections. 4. Prompt treatment can alleviate symptoms and prevent complications. Summary: - Choice B is not appropriate as notifying parents is not the priority. - Choice C is important but not the immediate action needed. - Choice D is premature without assessing the client first.
Question 2 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 technique involves applying manual pressure to the bladder to assist with urine elimination. It is a common method used in bladder training for clients with flaccid bladders to promote bladder emptying. Option A is incorrect because manual pressure should not be used to express urine as it can lead to complications. Option C is not appropriate for bladder training as it does not address bladder emptying. Option D is unrelated to bladder training and does not promote bladder emptying. The Crede maneuver is the most suitable option as it directly assists with bladder emptying in clients with flaccid bladders.
Question 3 of 5
A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?
Correct Answer: A
Rationale: The correct answer is A. Chromosomal abnormalities are the most common cause of early spontaneous abortions. This is because genetic defects in the embryo are a significant factor in early pregnancy loss. Chromosomal abnormalities can prevent the embryo from developing properly, leading to spontaneous abortion. B: Incompetent cervix is a cause of late miscarriages, not early spontaneous abortions. C: Infections can cause spontaneous abortions, but they are not the most common cause. D: While nutritional deficiencies can impact pregnancy outcomes, chromosomal abnormalities are more prevalent in early spontaneous abortions.
Question 4 of 5
The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?
Correct Answer: C
Rationale: The correct answer is C: Daily weight. Monitoring daily weight is crucial in determining fluid status as sudden weight gain may indicate fluid retention, a common complication in pneumonia. Skin turgor (B) is more indicative of hydration status, not fluid balance. Daily intake and output (A) provide information on fluid intake and output but may not reflect overall fluid balance. Vital signs every 4 hours (D) are important but do not directly assess fluid status. Daily weight is the most direct and reliable indicator of fluid status, making it the most important data to obtain in this situation.
Question 5 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 muscle weakness leads to ineffective breathing, posing the highest risk to the client's immediate survival. Priority is given to maintaining adequate oxygenation. Impaired physical mobility (A) is important but not life-threatening. Impaired skin integrity (C) and risk for infection (D) can be managed once the client's breathing is stabilized.