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 muscles weaken, leading to breathing difficulties. Priority is given to maintaining adequate oxygenation and ventilation. Impaired physical mobility (choice A) is important but not the highest priority. Impaired skin integrity (choice C) and risk for infection (choice D) may result from immobility but are secondary to the critical issue of breathing in this scenario.
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 life-threatening cardiac arrhythmias. Low calcium levels can be caused by TPN administration or poor calcium absorption following bowel resection. Immediate intervention may include administering IV calcium gluconate. A: Blood glucose of 140 mg/dL is within the normal range and not an immediate concern. B: White blood cell count of 8000/mm³ is within the normal range and does not require immediate intervention. C: Serum potassium of 3.8 mEq/L is within the normal range and does not pose an immediate threat.
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 may indicate a potential serious issue such as kidney problems or infection in the elderly. The kidneys are located in the lower back region, so pain in this area could be a sign of kidney dysfunction. The nurse should report this finding to the healthcare provider immediately for further evaluation and intervention. Choice A is incorrect because decreased urine output can be a common issue in older adults and may not always indicate a serious problem. Choice B is incorrect as loss of appetite can have various causes and may not be as urgent as lower back pain. Choice D is also incorrect as a persistent cough can have multiple causes, but it is not as concerning as potential kidney issues indicated by 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 drug, and its purpose is to control seizures. Seizure precautions aim to prevent injury during a seizure, ensuring the client's safety. Monitoring serum calcium levels (A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (B) is not a priority unless there are specific cardiac concerns. Encouraging a low-protein diet (D) is not necessary for phenytoin therapy.
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: Rationale: Choice C is correct because sudden weight gain can indicate fluid retention, a common complication in chronic kidney disease. This can lead to serious issues like heart failure. Monitoring weight daily (A) is important, but specifically reporting significant gains promptly (C) is crucial. Limiting fluid intake (B) is important, but not the top priority. Increasing protein intake (D) may worsen kidney function, so it's not recommended.