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. 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 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. To calculate the infusion rate, you need to divide the total amount infused by the total time in hours. Given contractions every 2-3 minutes, which is equivalent to 20-30 contractions per hour, the pump should infuse at 5 ml/hour to ensure proper medication delivery. Choices B, C, and D are incorrect because they do not correspond to the frequency of contractions and may lead to under or overmedication.
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 to relieve itching by providing airflow without causing damage to the cast or skin. It is safe and effective. Choice B: Twisting the cast back and forth may cause discomfort or injury to the child's arm. Choice C: Shaking powder into the cast can create a mess and may lead to skin irritation or infection. Choice D: Pushing a pencil under the cast edge can cause damage to the skin or lead to complications.
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. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring 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 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.