HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 9
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. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress. A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath. B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath. C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
Question 2 of 9
The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client's plan of care?
Correct Answer: C
Rationale: The correct answer is C. Implement seizure precautions. This is the most important intervention because phenytoin is an antiepileptic drug, and its purpose is to control seizures. Seizure precautions aim to prevent injury during a seizure, ensuring the client's safety. Monitoring serum calcium levels (A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (B) is not a priority unless there are specific cardiac concerns. Encouraging a low-protein diet (D) is not necessary for phenytoin therapy.
Question 3 of 9
A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
Correct Answer: A
Rationale: Step 1: A child with Leukemia undergoing chemotherapy often experiences anorexia, nausea, and vomiting, leading to altered nutrition. Step 2: Allowing the child to eat foods desired and tolerated promotes intake, ensuring adequate nutrition. Step 3: Restricting foods (Choice B) can exacerbate the child's already limited intake and lead to nutritional deficiencies. Step 4: Recommending the same foods as siblings (Choice C) may not address the specific needs of the child undergoing chemotherapy. Step 5: Encouraging large portions of food (Choice D) may overwhelm the child and worsen their symptoms.
Question 4 of 9
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. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress. A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath. B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath. C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
Question 5 of 9
A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
Question 6 of 9
Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. High levels of oxygen over a prolonged period can lead to oxygen toxicity. 2. Oxygen toxicity can cause lung damage and respiratory distress. 3. To prevent oxygen toxicity, it is crucial to monitor and limit the duration and amount of oxygen administered. 4. Therefore, avoiding the administration of high levels of oxygen for extended periods is the most effective intervention to prevent oxygen toxicity. Summary of other choices: B: Administering a sedative does not address the root cause of oxygen toxicity and can mask symptoms. C: Removing the nasal cannula at night can lead to hypoxia and is not a safe practice. D: Running oxygen through a hydration source does not prevent oxygen toxicity and is not a recognized intervention.
Question 7 of 9
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.
Question 8 of 9
A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client¢â‚¬â„¢s teaching plan?
Correct Answer: C
Rationale: The correct answer is C: Rotate insulin injection sites. This instruction is crucial to prevent lipohypertrophy, which can lead to inconsistent insulin absorption. By rotating injection sites, the client ensures proper insulin absorption and prevents complications. Checking blood glucose levels once a week (B) is not frequent enough for proper diabetes management. Avoiding all forms of sugar (A) is an outdated approach, as moderation is key. Monitoring urine ketone levels (D) is not as reliable as blood ketone testing for assessing diabetic ketoacidosis risk.
Question 9 of 9
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.