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 is a common side effect of amlodipine due to vasodilation. It can also lead to pulmonary edema, causing shortness of breath and crackles on auscultation. Therefore, assessing breath sounds is crucial to detect any signs of fluid overload and potential pulmonary complications. Bladder distention (A) is not directly related to the client's current symptoms. Serum albumin level (B) may indicate protein status but is not immediately necessary in this case. Abdominal girth (C) is more indicative of ascites or abdominal distension, not directly related to the client's edema and possible pulmonary complications.
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. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance. A: Activity tolerance is important but not the priority in acute glomerulonephritis. B: Absence of skin breakdown is important for overall health but not directly related to the condition. C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis. In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.
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. After a ureter lithotomy, the client may be at risk for respiratory complications due to anesthesia, pain, and immobility. Ineffective airway clearance can lead to hypoxia and respiratory distress, making it the highest priority. Altered nutrition, fluid volume excess, and activity intolerance are important but are secondary to the immediate threat of compromised airway and breathing in the postoperative period. Therefore, addressing airway clearance first is crucial to ensure optimal client outcomes.
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 shows empathy and encourages open communication. The nurse acknowledges the client's question and offers support by asking if they have any concerns. This response demonstrates active listening and shows the nurse is willing to address the client's emotional needs. Choice B is incorrect as it dismisses the client's question and focuses solely on the task at hand, lacking empathy. Choice C is incorrect as it provides a general statement about previous experiences without directly addressing the client's inquiry. Choice D is incorrect as it deflects the question and does not actively engage with the client's emotional 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. To calculate the infusion rate, you need to divide the total amount infused by the total time in hours. Given contractions every 2-3 minutes, which is equivalent to 20-30 contractions per hour, the pump should infuse at 5 ml/hour to ensure proper medication delivery. Choices B, C, and D are incorrect because they do not correspond to the frequency of contractions and may lead to under or overmedication.