HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)
Correct Answer: C
Rationale: The correct answer is C: Presence of uremic frost. In hyperosmolar hyperglycemic nonketotic syndrome (HHNS), there is severe hyperglycemia leading to osmotic diuresis, dehydration, and hyperosmolality. Uremic frost is not a symptom of HHNS but is associated with severe chronic kidney disease. Increased heart rate, visual disturbances, and decreased mentation are common signs of HHNS due to the effects of hyperglycemia on the body's organs and nervous system.
Question 2 of 5
An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?
Correct Answer: D
Rationale: The correct answer is D: "I understand you are frustrated with the wait time." This response demonstrates empathy, validates the client's feelings, and shows understanding without admitting fault. It acknowledges the client's emotions while maintaining professionalism. A: "The emergency department is very busy at this time." This response does not address the client's feelings of frustration and may come off as dismissive. B: "I'll let you see the doctor next because you've waited so long." Giving special treatment based on complaining sets a poor precedent and is unfair to other patients. C: "I'm doing the best I can for the sickest clients first." While this response emphasizes prioritization based on medical need, it does not address the client's feelings of frustration and may escalate the situation.
Question 3 of 5
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
Correct Answer: A
Rationale: The correct answer is A. The highest priority is ensuring the safety of the client. By raising the side rails and placing the call bell within reach, the nurse can prevent falls and easily attend to any urgent needs. This intervention promotes the client's physical safety and ensures immediate assistance if necessary. Choice B is incorrect because pushing effectively is important but not the highest priority. Choice C is incorrect as timing and recording contractions are important but not as critical as ensuring immediate safety. Choice D is incorrect as positioning for anesthesia distribution is important but ensuring safety takes precedence.
Question 4 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 5 of 5
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? Seizures are a common complication of brain tumors and can provide critical information about the tumor's location and potential impact on the client's neurological function. Seizures can also indicate increased intracranial pressure. Asking about seizures helps assess the client's safety and neurological status. Rationales for incorrect choices: A: When did your symptoms first begin? While important, the onset of symptoms may not directly impact the client's immediate care needs as much as the presence of seizures. B: Can you describe the pain and how it feels? Pain can be a symptom of a brain tumor, but seizures are more indicative of neurological involvement. C: Do you have any changes in vision? Vision changes can occur with brain tumors, but seizures are a more urgent symptom that requires immediate attention.