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. Rationale: 1. Increasing oxygen flow in COPD patients can lead to oxygen toxicity, causing lethargy and confusion. 2. Lowering the oxygen rate will help alleviate oxygen toxicity symptoms. 3. This is an immediate intervention to address the client's condition. Summary: A: Repositioning the nasal cannula won't address the underlying issue of oxygen toxicity. C: Encouraging cough and deep breathing won't resolve the client's lethargy and confusion. D: Monitoring oxygen saturation is important, but lowering the oxygen rate is more urgent in this situation.
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: Rationale: 1. Pelvic pain and dysmenorrhea could indicate gynecological issues. 2. Referring the client for a pelvic exam allows for a thorough assessment. 3. It helps identify any underlying conditions or infections. 4. Prompt treatment can alleviate symptoms and prevent complications. Summary: - Choice B is not appropriate as notifying parents is not the priority. - Choice C is important but not the immediate action needed. - Choice D is premature without assessing the client first.
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. Placing the child in a mist tent is the first intervention because the child is presenting with symptoms of epiglottitis, a potentially life-threatening condition. The mist tent helps to humidify the airway and can provide relief for the child's breathing difficulties. It is important to maintain a patent airway and alleviate respiratory distress as a priority. Option B (obtain a sputum culture) is not the first priority as it does not address the immediate need to secure the airway and provide relief for the child's breathing difficulties. Option C (prepare for an emergent tracheostomy) is not the first intervention as it is an invasive procedure and should only be considered if other interventions fail to secure the airway. Option D (examine the child's oropharynx and report findings) is important but not the first priority in this scenario. Immediate intervention to address the respiratory distress is crucial.
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 technique involves applying manual pressure to the bladder to assist with urine elimination. It is a common method used in bladder training for clients with flaccid bladders to promote bladder emptying. Option A is incorrect because manual pressure should not be used to express urine as it can lead to complications. Option C is not appropriate for bladder training as it does not address bladder emptying. Option D is unrelated to bladder training and does not promote bladder emptying. The Crede maneuver is the most suitable option as it directly assists with bladder emptying in clients with flaccid bladders.
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. Chromosomal abnormalities are the most common cause of early spontaneous abortions. This is because genetic defects in the embryo are a significant factor in early pregnancy loss. Chromosomal abnormalities can prevent the embryo from developing properly, leading to spontaneous abortion. B: Incompetent cervix is a cause of late miscarriages, not early spontaneous abortions. C: Infections can cause spontaneous abortions, but they are not the most common cause. D: While nutritional deficiencies can impact pregnancy outcomes, chromosomal abnormalities are more prevalent in early spontaneous abortions.