HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 4
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 2 of 4
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 coagulation. 2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy. 3. INR is more specific for monitoring heparin therapy compared to other options. 4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring. 5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
Question 3 of 4
The nurse is assessing a client who is 2 days post-op following abdominal surgery. 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. This is because the client is experiencing evisceration, which is a medical emergency requiring immediate attention to prevent infection and further complications. By applying a sterile saline dressing, the nurse can protect the exposed bowel from contamination, maintain moisture, and promote healing. This action helps to reduce the risk of infection and provides a temporary barrier until further interventions can be implemented. Summary of Incorrect Choices: B: Notifying the healthcare provider is important, but immediate action to protect the exposed bowel is the priority. C: Administering pain medication does not address the primary concern of protecting the exposed bowel. D: Covering the wound with an abdominal binder does not provide the necessary protection and could potentially exacerbate the situation by applying pressure to the protruding bowel.
Question 4 of 4
The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic before meals. Administering an antiemetic before meals helps prevent and manage nausea associated with chemotherapy by blocking receptors that trigger nausea and vomiting. This intervention targets the root cause of the symptom. Providing frequent mouth care (B) may help with taste changes but does not directly address nausea. Encouraging small, frequent meals (C) and offering clear liquids (D) may be helpful for some clients, but they do not specifically target nausea caused by chemotherapy.