HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. It is a concerning sign in a client with CHF and fluid volume overload, indicating possible worsening of pulmonary congestion. Shortness of breath can be a result of fluid accumulation in the lungs, leading to respiratory distress. Reporting this finding promptly to the healthcare provider is crucial for timely intervention to prevent further complications. A: Weight gain of 2 pounds in 24 hours could be an early sign of fluid retention, but shortness of breath is a more critical finding in this scenario. B: Presence of a cough may indicate pulmonary congestion, but shortness of breath is a more severe symptom that requires immediate attention. C: Edema in the lower extremities is a common manifestation of fluid overload but may not be as urgent as shortness of breath in indicating worsening condition.
Question 2 of 5
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
Correct Answer: C
Rationale: The correct answer is C: Partial thromboplastin time (PTT). PTT measures the effectiveness of heparin therapy by assessing the clotting time. Monitoring PTT helps ensure the client is within the therapeutic range for anticoagulation. Platelet count (A) monitors for thrombocytopenia, not heparin effectiveness. Prothrombin time (PT) (B) primarily assesses warfarin therapy. Hemoglobin level (D) monitors for anemia, not heparin effectiveness.
Question 3 of 5
The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
Correct Answer: A
Rationale: The correct first action for the nurse to take in this scenario is to apply a sterile saline dressing to the wound. This is important to prevent infection and protect the exposed bowel. Covering the wound with a dressing helps maintain a sterile environment and prevents further contamination. Notifying the healthcare provider is important but should come after immediate intervention. Administering pain medication is not the priority in this situation as the main concern is the protruding bowel. Using an abdominal binder is not appropriate and could potentially worsen the condition. Therefore, applying a sterile saline dressing is the most appropriate initial action to address the client's immediate needs.
Question 4 of 5
A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. The client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. 2. Administering 15 grams of carbohydrate will help raise the blood glucose level quickly. 3. Carbohydrates are the preferred treatment for hypoglycemia in clients with diabetes. 4. Glucagon injection is used for severe hypoglycemia when the client is unconscious. 5. Providing a snack with protein is not ideal for immediate treatment of hypoglycemia. 6. Encouraging the client to rest is not a priority over addressing the low blood glucose level.
Question 5 of 5
A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
Correct Answer: B
Rationale: The correct answer is B: It prevents the blood from clotting. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thus preventing blood from clotting excessively. This helps reduce the risk of thrombosis. Incorrect choices: A: It dissolves blood clots - Warfarin does not dissolve existing blood clots; it prevents new clots from forming. C: It thins the blood - While warfarin affects the clotting process, it does not actually thin the blood. D: It decreases the risk of infection - Warfarin is not used to decrease the risk of infection; its primary function is to prevent clot formation.