HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
Correct Answer: A
Rationale: The correct answer is A: Ineffective airway clearance. Postoperative clients are at risk for respiratory complications such as atelectasis due to anesthesia effects and decreased mobility. In this case, a flank incision for ureter lithotomy may cause pain, impairing deep breathing and coughing, leading to ineffective airway clearance. Priority is given to airway management to prevent respiratory complications. Altered nutrition (B), fluid volume excess (C), and activity intolerance (D) are important but not as immediate as ensuring adequate oxygenation and preventing respiratory compromise.
Question 2 of 5
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
Correct Answer: A
Rationale: The correct answer is A (5 ml/hour) because with contractions every 2-3 minutes, the pump should infuse at a slow rate to prevent overstimulation of the uterus, which can lead to fetal distress. Infusing at a higher rate (B, C, D) could potentially increase contractions frequency and intensity, risking complications. It is crucial to maintain a balance to ensure safe labor progression.
Question 3 of 5
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
Correct Answer: A
Rationale: The correct answer is A - Blow cool air from a hair dryer under the cast. This method helps relieve itching without causing harm or compromising the cast. It allows for ventilation and cooling without introducing foreign objects that may cause skin irritation or damage. The other choices are incorrect because twisting the cast, shaking powder into it, or pushing a pencil under the cast can all potentially damage the cast or harm the child's skin. It is important to follow appropriate and safe methods to address itching while the cast is in place.
Question 4 of 5
What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
Correct Answer: B
Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. The nurse should monitor the client's oral cavity regularly for signs of gum overgrowth. Bladder palpation (A) is not relevant to phenytoin side effects. Blood glucose monitoring (C) is typically not associated with phenytoin use. Auscultation of breath sounds (D) is not a specific assessment for phenytoin side effects.
Question 5 of 5
When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C: Select a large, deep muscle mass. This is important because using a large, deep muscle mass helps distribute the medication effectively and reduces the risk of tissue irritation and nerve damage. It also allows for better absorption of the medication. Option A is incorrect because instilling the medication quickly can cause pain and tissue damage. Option B is incorrect as inserting the needle slowly does not necessarily impact the effectiveness of the injection. Option D is incorrect as using a short, small gauge needle may not reach the desired muscle depth for optimal medication absorption. Therefore, selecting a large, deep muscle mass is the best intervention for administering an intramuscular injection containing a painful medication.