HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A. Placing the child in a mist tent is the first intervention because the child is presenting with symptoms of epiglottitis, a potentially life-threatening condition. The mist tent helps to humidify the airway and can provide relief for the child's breathing difficulties. It is important to maintain a patent airway and alleviate respiratory distress as a priority. Option B (obtain a sputum culture) is not the first priority as it does not address the immediate need to secure the airway and provide relief for the child's breathing difficulties. Option C (prepare for an emergent tracheostomy) is not the first intervention as it is an invasive procedure and should only be considered if other interventions fail to secure the airway. Option D (examine the child's oropharynx and report findings) is important but not the first priority in this scenario. Immediate intervention to address the respiratory distress is crucial.
Question 2 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 3 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 4 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.
Question 5 of 5
The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
Correct Answer: C
Rationale: The correct action for the nurse to implement first is to stop the infusion (Choice C). Oliguria and high serum potassium level indicate potential renal impairment or potassium retention, which can lead to hyperkalemia. Stopping the infusion is crucial to prevent further potassium buildup and worsening kidney function. Notifying the healthcare provider (Choice A) can be done after stopping the infusion. Decreasing the infusion rate (Choice B) may not be sufficient to address the immediate risk of hyperkalemia. Administering sodium polystyrene sulfonate (Kayexalate) (Choice D) is a treatment for hyperkalemia but should not be the initial action in this situation.