HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client¢â‚¬â„¢s teaching plan?
Correct Answer: C
Rationale: The correct answer is C: Rotate insulin injection sites. This is important to prevent lipodystrophy and ensure proper insulin absorption. Option A is incorrect because the client does not need to avoid all forms of sugar, but rather manage their intake. Option B is incorrect as blood glucose levels should be checked frequently, not just once a week. Option D is incorrect as monitoring urine ketone levels is not a primary teaching point for a newly diagnosed diabetic client.
Question 2 of 5
A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?
Correct Answer: B
Rationale: The correct answer is B: Avoid alcohol while taking this medication. Phenytoin interacts negatively with alcohol, increasing the risk of side effects and reducing its effectiveness in controlling seizures. Alcohol may also worsen drowsiness and dizziness caused by phenytoin. Choice A is incorrect as taking phenytoin with meals can decrease its absorption. Choice C is unrelated to phenytoin therapy. Choice D is incorrect as phenytoin should be taken at regular intervals throughout the day to maintain therapeutic levels.
Question 3 of 5
A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. It is a concerning sign in a client with CHF and fluid volume overload, indicating possible worsening of pulmonary congestion. Shortness of breath can be a result of fluid accumulation in the lungs, leading to respiratory distress. Reporting this finding promptly to the healthcare provider is crucial for timely intervention to prevent further complications. A: Weight gain of 2 pounds in 24 hours could be an early sign of fluid retention, but shortness of breath is a more critical finding in this scenario. B: Presence of a cough may indicate pulmonary congestion, but shortness of breath is a more severe symptom that requires immediate attention. C: Edema in the lower extremities is a common manifestation of fluid overload but may not be as urgent as shortness of breath in indicating worsening condition.
Question 4 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 5 of 5
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
Correct Answer: C
Rationale: The correct answer is C: Partial thromboplastin time (PTT). PTT measures the effectiveness of heparin therapy by assessing the clotting time. Monitoring PTT helps ensure the client is within the therapeutic range for anticoagulation. Platelet count (A) monitors for thrombocytopenia, not heparin effectiveness. Prothrombin time (PT) (B) primarily assesses warfarin therapy. Hemoglobin level (D) monitors for anemia, not heparin effectiveness.