HESI RN
HESI RN CAT Exit Exam Questions
Question 1 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 2 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 3 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.
Question 4 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 a high serum potassium level indicate the client is at risk for hyperkalemia, which can be exacerbated by the potassium chloride infusion. Stopping the infusion is crucial to prevent further elevation of potassium levels and potential cardiac complications. Choice A (Notify the healthcare provider) is not the first action as immediate intervention is needed to prevent harm. Choice B (Decrease the rate of the IV infusion) is not sufficient to address the immediate risk of hyperkalemia. Choice D (Administer sodium polystyrene sulfonate) is not appropriate as the first action and should only be considered after stabilizing the client's condition.
Question 5 of 5
The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Serum calcium of 7.8 mg/dL. This finding indicates hypocalcemia, which can lead to life-threatening cardiac arrhythmias. Low calcium levels can be caused by TPN administration or poor calcium absorption following bowel resection. Immediate intervention may include administering IV calcium gluconate. A: Blood glucose of 140 mg/dL is within the normal range and not an immediate concern. B: White blood cell count of 8000/mm³ is within the normal range and does not require immediate intervention. C: Serum potassium of 3.8 mEq/L is within the normal range and does not pose an immediate threat.