HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?
Correct Answer: D
Rationale: The correct answer is D: Breath sounds. Pitting edema can be a sign of heart failure, a potential side effect of amlodipine. Assessing breath sounds can help determine if the edema is due to heart failure. Bladder distention (A) is not directly related to edema caused by amlodipine. Serum albumin level (B) is important for assessing protein status but not the immediate concern in this scenario. Abdominal girth (C) is more relevant for assessing liver function or ascites, not the primary concern with pitting edema.
Question 2 of 5
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
Correct Answer: D
Rationale: The correct answer is D because maintaining fluid balance is crucial in acute glomerulonephritis to prevent complications like fluid overload or dehydration. A urine output of 1 to 2 ml/kg/hr indicates proper kidney function. A: Activity tolerance is important but not the top priority. B: Absence of skin breakdown is important but not directly related to the condition. C: Nutritional status is vital but not as urgent as fluid balance in this case.
Question 3 of 5
A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
Correct Answer: A
Rationale: The correct answer is A: Ineffective airway clearance. Postoperative clients are at risk for respiratory complications such as atelectasis due to anesthesia effects and decreased mobility. In this case, a flank incision for ureter lithotomy may cause pain, impairing deep breathing and coughing, leading to ineffective airway clearance. Priority is given to airway management to prevent respiratory complications. Altered nutrition (B), fluid volume excess (C), and activity intolerance (D) are important but not as immediate as ensuring adequate oxygenation and preventing respiratory compromise.
Question 4 of 5
When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and encourages open communication. By acknowledging the client's question and offering to address any concerns, the nurse shows understanding and willingness to support the client emotionally. This response also promotes a therapeutic relationship and allows the client to express his feelings and fears. Choices B, C, and D are incorrect because they do not address the client's emotional needs or provide an opportunity for him to discuss his concerns about death. B and C are dismissive and do not encourage further discussion, while D minimizes the client's feelings and redirects the conversation away from his concerns.
Question 5 of 5
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
Correct Answer: A
Rationale: The correct answer is A (5 ml/hour) because with contractions every 2-3 minutes, the pump should infuse at a slow rate to prevent overstimulation of the uterus, which can lead to fetal distress. Infusing at a higher rate (B, C, D) could potentially increase contractions frequency and intensity, risking complications. It is crucial to maintain a balance to ensure safe labor progression.