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 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 2 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 3 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.
Question 4 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 by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thus preventing blood from clotting excessively. This helps reduce the risk of thrombosis. Incorrect choices: A: It dissolves blood clots - Warfarin does not dissolve existing blood clots; it prevents new clots from forming. C: It thins the blood - While warfarin affects the clotting process, it does not actually thin the blood. D: It decreases the risk of infection - Warfarin is not used to decrease the risk of infection; its primary function is to prevent clot formation.
Question 5 of 5
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
Correct Answer: C
Rationale: Rationale: 1. Heparin primarily affects the intrinsic pathway of the coagulation cascade, monitored by PTT. 2. However, PTT can be influenced by various factors. 3. INR is a standardized measure of PT, more reliable for monitoring heparin therapy effectiveness. 4. Thus, INR is the most appropriate choice for monitoring heparin therapy. Other options are not as specific to heparin's action.