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. 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 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. With heparin being an anticoagulant, monitoring PTT helps ensure the client is within the therapeutic range to prevent clot formation. A - Platelet count assesses risk of bleeding, not heparin effectiveness. B - Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. D - Hemoglobin level 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 action for the nurse to take first is to apply a sterile saline dressing to the wound (Choice A). This is because the client's situation suggests an incisional dehiscence, which is a surgical complication requiring immediate attention to prevent infection and further complications. Applying a sterile saline dressing helps protect the exposed bowel from contamination and dehydration. Notifying the healthcare provider (Choice B) is important, but immediate wound care is the priority to prevent complications. Administering pain medication (Choice C) can wait until after the wound is properly dressed and assessed. Covering the wound with an abdominal binder (Choice D) is not appropriate in this situation as it does not address the urgent need to protect the exposed bowel and prevent infection.
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: The correct action is to administer 15 grams of carbohydrate because the client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. Carbohydrates will quickly raise the blood sugar level. Glucagon injection is used for severe hypoglycemia when the client is unconscious. Providing a snack with protein is not the immediate action needed to raise the blood sugar rapidly. Encouraging rest is not effective in treating hypoglycemia.
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 as an anticoagulant by inhibiting the production of certain clotting factors in the liver. This prevents the formation of blood clots and reduces the risk of conditions like deep vein thrombosis or stroke. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones. Choice C is misleading as it does not actually "thin" the blood but affects its ability to clot. Choice D is unrelated to the mechanism of action of warfarin.