HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?
Correct Answer: B
Rationale: The correct answer is B: Ineffective breathing pattern. In late-stage ALS, respiratory muscle weakness leads to ineffective breathing, posing the highest risk to the client's immediate survival. Priority is given to maintaining adequate oxygenation. Impaired physical mobility (A) is important but not life-threatening. Impaired skin integrity (C) and risk for infection (D) can be managed once the client's breathing is stabilized.
Question 2 of 5
The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Serum calcium of 7.8 mg/dL. This finding indicates hypocalcemia, which can lead to serious complications like tetany or seizures. Hypocalcemia is a common complication after bowel resection due to impaired absorption. Immediate intervention is crucial to prevent further complications. A: Blood glucose of 140 mg/dL is within normal range and does not require immediate intervention. B: White blood cell count of 8000/mm³ is within normal range and does not require immediate intervention. C: Serum potassium of 3.8 mEq/L is within normal range and does not require immediate intervention.
Question 3 of 5
The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
Correct Answer: C
Rationale: The correct answer is C because pain in the lower back in an older client can be indicative of a serious underlying issue such as a kidney infection, kidney stones, or spinal issues. The nurse should report this finding to the healthcare provider promptly for further evaluation and intervention to prevent potential complications. Choice A is not as urgent as it may indicate dehydration or renal issues, but it is not as critical as the potential issues related to back pain. Choice B, loss of appetite, is important but may not be as urgent as potential kidney or spinal issues. Choice D, a persistent cough, is also important but may not be as immediately concerning as the possibility of a serious condition related to lower back pain in an older client.
Question 4 of 5
The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client's plan of care?
Correct Answer: C
Rationale: The correct answer is C: Implement seizure precautions. This is the most important intervention because phenytoin is an antiepileptic medication used for seizure control. Seizure precautions aim to prevent injury during a seizure by ensuring a safe environment for the client. Monitoring serum calcium levels (choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (choice B) is not specifically indicated for clients on phenytoin. Encouraging a low-protein diet (choice D) is not a priority in the care of a client receiving phenytoin for seizure control.
Question 5 of 5
The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?
Correct Answer: C
Rationale: Step 1: The correct answer is C. Rapid weight gain may indicate fluid retention, a common complication in chronic kidney disease. Step 2: Monitoring daily weights (A) is important, but rapid weight gain is more indicative of fluid overload. Step 3: Limiting fluid intake (B) is crucial, but not the most important as fluid balance can be affected by various factors. Step 4: Increasing protein intake (D) is not recommended in advanced kidney disease due to potential strain on the kidneys.