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 technique involves applying manual pressure to the bladder to assist with urine elimination. It is a common method used in bladder training for clients with flaccid bladders to promote bladder emptying. Option A is incorrect because manual pressure should not be used to express urine as it can lead to complications. Option C is not appropriate for bladder training as it does not address bladder emptying. Option D is unrelated to bladder training and does not promote bladder emptying. The Crede maneuver is the most suitable option as it directly assists with bladder emptying in clients with flaccid bladders.
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. 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 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 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 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 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.
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 serious complications like tetany or seizures. Hypocalcemia is a common complication after bowel resection due to impaired absorption. Immediate intervention is crucial to prevent further complications. A: Blood glucose of 140 mg/dL is within normal range and does not require immediate intervention. B: White blood cell count of 8000/mm³ is within normal range and does not require immediate intervention. C: Serum potassium of 3.8 mEq/L is within normal range and does not require immediate intervention.