HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 9
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. After a ureter lithotomy, the client may be at risk for respiratory complications due to anesthesia, pain, and immobility. Ineffective airway clearance can lead to hypoxia and respiratory distress, making it the highest priority. Altered nutrition, fluid volume excess, and activity intolerance are important but are secondary to the immediate threat of compromised airway and breathing in the postoperative period. Therefore, addressing airway clearance first is crucial to ensure optimal client outcomes.
Question 2 of 9
A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?
Correct Answer: A
Rationale: The correct answer is A because chromosomal abnormalities are indeed the most common cause of early spontaneous abortions. These abnormalities can occur during fertilization or early cell division, leading to non-viable embryos. Choice B, incompetent cervix, typically causes late-term miscarriages. Choice C, infections, can contribute to miscarriages but are not the most common cause. Choice D, nutritional deficiencies, can impact pregnancy outcomes but are not the primary cause of early spontaneous abortions. In summary, the correct answer A is supported by the fact that chromosomal abnormalities are the leading cause of early spontaneous abortions, while the other choices are either more relevant to late-term miscarriages or less commonly associated with early pregnancy loss.
Question 3 of 9
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 because using a large, deep muscle mass ensures proper absorption and distribution of the medication, reducing the risk of tissue damage or irritation. Rationale: 1. Instilling the medication quickly (Choice A) can cause discomfort and increase the risk of tissue trauma. 2. Inserting the needle slowly (Choice B) can also lead to pain and discomfort for the patient. 3. Using a short, small gauge needle (Choice D) may not reach the deep muscle mass and can cause inadequate absorption of the medication. In summary, selecting a large, deep muscle mass ensures optimal medication delivery and minimizes discomfort and tissue damage compared to the other choices.
Question 4 of 9
A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
Correct Answer: C
Rationale: The correct answer is C because full-thickness burns destroy nerve endings, resulting in the absence of pain sensation. The dry, waxy, and white appearance indicates tissue destruction extending through the epidermis and dermis. Choices A and D are incorrect because dry, waxy, and white appearance signifies a deeper burn, not a minor or superficial burn, and second-degree burns typically involve pain sensation. Choice B is incorrect as nerve compression does not explain the lack of pain sensation in a full-thickness burn.
Question 5 of 9
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B: Instill the first dose of nystatin (Mycostatin) vaginally per applicator. This is the appropriate action for a college student with symptoms of a vaginal infection with a 'cottage cheese' appearance discharge, which is indicative of a yeast infection (most likely caused by Candida). Nystatin is an antifungal medication effective against Candida, hence addressing the root cause of the infection. It is essential to start with the treatment first to alleviate the symptoms and prevent further complications. Incorrect choices: A: Cleansing the perineum with warm soapy water may provide some comfort but does not address the underlying infection. C: Performing a glucose measurement is not necessary at this stage as the symptoms suggest a yeast infection, not diabetes. D: Obtaining a blood specimen for STDs is not the priority in this case as the symptoms are indicative of a yeast infection, not an STD.
Question 6 of 9
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
Question 7 of 9
A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention. A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder. C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying. D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.
Question 8 of 9
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 9 of 9
The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
Correct Answer: C
Rationale: The correct action for the nurse to implement first is to stop the infusion (Choice C). Oliguria and a high serum potassium level indicate the client is at risk for hyperkalemia, which can be exacerbated by the potassium chloride infusion. Stopping the infusion is crucial to prevent further elevation of potassium levels and potential cardiac complications. Choice A (Notify the healthcare provider) is not the first action as immediate intervention is needed to prevent harm. Choice B (Decrease the rate of the IV infusion) is not sufficient to address the immediate risk of hyperkalemia. Choice D (Administer sodium polystyrene sulfonate) is not appropriate as the first action and should only be considered after stabilizing the client's condition.