HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Lower the oxygen rate. Increasing oxygen flow too quickly can lead to oxygen toxicity in COPD patients, causing symptoms like lethargy and confusion. Lowering the oxygen rate will help alleviate the symptoms and prevent further harm. Repositioning the nasal cannula (choice A) is not the priority in this situation. Encouraging coughing and deep breathing (choice C) may not address the immediate issue of oxygen toxicity. Monitoring oxygen saturation (choice D) is important but should follow lowering the oxygen rate to address the current symptoms.
Question 2 of 5
A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Refer the client to a healthcare provider for a pelvic examination. This is the first action the nurse should take because the client is experiencing abdominal pain and dysmenorrhea, which could indicate a gynecological issue. A pelvic examination by a healthcare provider is necessary to assess for any potential reproductive system problems, such as ovarian cysts, endometriosis, or pelvic inflammatory disease. This examination will provide valuable information to diagnose and treat the underlying cause of the client's symptoms. Choice B is incorrect because notifying the parents to pick up the client does not address the primary concern of evaluating the abdominal pain and dysmenorrhea. Choice C is also incorrect as determining the date of the client's last menstrual period, while important, does not take precedence over a thorough pelvic examination. Choice D is incorrect as asking the client to lie down for a pelvic examination should only be done by a healthcare provider in a proper clinical setting, not in a school clinic.
Question 3 of 5
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 4 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 is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention. A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder. C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying. D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.
Question 5 of 5
A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?
Correct Answer: A
Rationale: The correct answer is A because chromosomal abnormalities are indeed the most common cause of early spontaneous abortions. These abnormalities can occur during fertilization or early cell division, leading to non-viable embryos. Choice B, incompetent cervix, typically causes late-term miscarriages. Choice C, infections, can contribute to miscarriages but are not the most common cause. Choice D, nutritional deficiencies, can impact pregnancy outcomes but are not the primary cause of early spontaneous abortions. In summary, the correct answer A is supported by the fact that chromosomal abnormalities are the leading cause of early spontaneous abortions, while the other choices are either more relevant to late-term miscarriages or less commonly associated with early pregnancy loss.