HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?
Correct Answer: B
Rationale: The correct answer is B: Avoid alcohol while taking this medication. Phenytoin interacts negatively with alcohol, increasing the risk of side effects and reducing its effectiveness in controlling seizures. Alcohol may also worsen drowsiness and dizziness caused by phenytoin. Choice A is incorrect as taking phenytoin with meals can decrease its absorption. Choice C is unrelated to phenytoin therapy. Choice D is incorrect as phenytoin should be taken at regular intervals throughout the day to maintain therapeutic levels.
Question 2 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
Correct Answer: C
Rationale: Step 1: Check the client's oxygen saturation level to assess the effectiveness of oxygen therapy. Step 2: If oxygen saturation is low, adjust oxygen flow rate accordingly. Step 3: If oxygen saturation is adequate, further assess the client's condition. Step 4: Instructing deep breathing and coughing may help with airway clearance but should not be the first action. Step 5: Placing the client in high-Fowler's position may aid breathing but does not address the immediate need to assess oxygen saturation level.
Question 3 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 4 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 5 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.