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: The correct answer is A: Refer the client to a healthcare provider for a pelvic examination. This is the first action the nurse should take because the client is experiencing abdominal pain and dysmenorrhea, which could indicate a gynecological issue. A pelvic examination by a healthcare provider is necessary to assess for any potential reproductive system problems, such as ovarian cysts, endometriosis, or pelvic inflammatory disease. This examination will provide valuable information to diagnose and treat the underlying cause of the client's symptoms. Choice B is incorrect because notifying the parents to pick up the client does not address the primary concern of evaluating the abdominal pain and dysmenorrhea. Choice C is also incorrect as determining the date of the client's last menstrual period, while important, does not take precedence over a thorough pelvic examination. Choice D is incorrect as asking the client to lie down for a pelvic examination should only be done by a healthcare provider in a proper clinical setting, not in a school clinic.
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 is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention. A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder. C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying. D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.
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 because chromosomal abnormalities are indeed the most common cause of early spontaneous abortions. These abnormalities can occur during fertilization or early cell division, leading to non-viable embryos. Choice B, incompetent cervix, typically causes late-term miscarriages. Choice C, infections, can contribute to miscarriages but are not the most common cause. Choice D, nutritional deficiencies, can impact pregnancy outcomes but are not the primary cause of early spontaneous abortions. In summary, the correct answer A is supported by the fact that chromosomal abnormalities are the leading cause of early spontaneous abortions, while the other choices are either more relevant to late-term miscarriages or less commonly associated with early pregnancy loss.
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. Daily weight is the most important data to assess fluid status in a client with pneumonia as weight changes can indicate fluid retention or loss, a crucial aspect in managing pneumonia. Skin turgor (B) is more indicative of hydration status, not overall fluid balance. Daily intake and output (A) is important but does not provide a direct measure of fluid status. Vital signs (D) are important for monitoring overall health but do not directly assess fluid status.
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 muscles weaken, leading to breathing difficulties. Priority is given to maintaining adequate oxygenation and ventilation. Impaired physical mobility (choice A) is important but not the highest priority. Impaired skin integrity (choice C) and risk for infection (choice D) may result from immobility but are secondary to the critical issue of breathing in this scenario.