HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?
Correct Answer: D
Rationale: The correct answer is D: "I understand you are frustrated with the wait time." This response demonstrates empathy, validates the client's feelings, and shows understanding without admitting fault. It acknowledges the client's emotions while maintaining professionalism. A: "The emergency department is very busy at this time." This response does not address the client's feelings of frustration and may come off as dismissive. B: "I'll let you see the doctor next because you've waited so long." Giving special treatment based on complaining sets a poor precedent and is unfair to other patients. C: "I'm doing the best I can for the sickest clients first." While this response emphasizes prioritization based on medical need, it does not address the client's feelings of frustration and may escalate the situation.
Question 2 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
Correct Answer: B
Rationale: The correct answer is B: Lower the oxygen rate. Rationale: 1. Increasing oxygen flow in COPD patients can lead to oxygen toxicity, causing lethargy and confusion. 2. Lowering the oxygen rate will help alleviate oxygen toxicity symptoms. 3. This is an immediate intervention to address the client's condition. Summary: A: Repositioning the nasal cannula won't address the underlying issue of oxygen toxicity. C: Encouraging cough and deep breathing won't resolve the client's lethargy and confusion. D: Monitoring oxygen saturation is important, but lowering the oxygen rate is more urgent in this situation.
Question 3 of 5
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? Seizures are a common complication of brain tumors and can provide critical information about the tumor's location and potential impact on the client's neurological function. Seizures can also indicate increased intracranial pressure. Asking about seizures helps assess the client's safety and neurological status. Rationales for incorrect choices: A: When did your symptoms first begin? While important, the onset of symptoms may not directly impact the client's immediate care needs as much as the presence of seizures. B: Can you describe the pain and how it feels? Pain can be a symptom of a brain tumor, but seizures are more indicative of neurological involvement. C: Do you have any changes in vision? Vision changes can occur with brain tumors, but seizures are a more urgent symptom that requires immediate attention.
Question 4 of 5
A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
Correct Answer: A
Rationale: Rationale: 1. Pelvic pain and dysmenorrhea could indicate gynecological issues. 2. Referring the client for a pelvic exam allows for a thorough assessment. 3. It helps identify any underlying conditions or infections. 4. Prompt treatment can alleviate symptoms and prevent complications. Summary: - Choice B is not appropriate as notifying parents is not the priority. - Choice C is important but not the immediate action needed. - Choice D is premature without assessing the client first.
Question 5 of 5
A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A. Placing the child in a mist tent is the first intervention because the child is presenting with symptoms of epiglottitis, a potentially life-threatening condition. The mist tent helps to humidify the airway and can provide relief for the child's breathing difficulties. It is important to maintain a patent airway and alleviate respiratory distress as a priority. Option B (obtain a sputum culture) is not the first priority as it does not address the immediate need to secure the airway and provide relief for the child's breathing difficulties. Option C (prepare for an emergent tracheostomy) is not the first intervention as it is an invasive procedure and should only be considered if other interventions fail to secure the airway. Option D (examine the child's oropharynx and report findings) is important but not the first priority in this scenario. Immediate intervention to address the respiratory distress is crucial.