HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
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 high serum potassium level indicate potential renal impairment or potassium retention, which can lead to hyperkalemia. Stopping the infusion is crucial to prevent further potassium buildup and worsening kidney function. Notifying the healthcare provider (Choice A) can be done after stopping the infusion. Decreasing the infusion rate (Choice B) may not be sufficient to address the immediate risk of hyperkalemia. Administering sodium polystyrene sulfonate (Kayexalate) (Choice D) is a treatment for hyperkalemia but should not be the initial action in this situation.
Question 2 of 5
The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
Correct Answer: C
Rationale: The correct answer is C because pain in the lower back in an older client can be indicative of a serious underlying issue such as a kidney infection, kidney stones, or spinal issues. The nurse should report this finding to the healthcare provider promptly for further evaluation and intervention to prevent potential complications. Choice A is not as urgent as it may indicate dehydration or renal issues, but it is not as critical as the potential issues related to back pain. Choice B, loss of appetite, is important but may not be as urgent as potential kidney or spinal issues. Choice D, a persistent cough, is also important but may not be as immediately concerning as the possibility of a serious condition related to lower back pain in an older client.
Question 3 of 5
The nurse is planning care for a client who is receiving phenytoin (Dilantin) for seizure control. Which intervention is most important to include in this client's plan of care?
Correct Answer: C
Rationale: The correct answer is C: Implement seizure precautions. This is the most important intervention because phenytoin is an antiepileptic medication used for seizure control. Seizure precautions aim to prevent injury during a seizure by ensuring a safe environment for the client. Monitoring serum calcium levels (choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (choice B) is not specifically indicated for clients on phenytoin. Encouraging a low-protein diet (choice D) is not a priority in the care of a client receiving phenytoin for seizure control.
Question 4 of 5
The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?
Correct Answer: C
Rationale: Step 1: The correct answer is C. Rapid weight gain may indicate fluid retention, a common complication in chronic kidney disease. Step 2: Monitoring daily weights (A) is important, but rapid weight gain is more indicative of fluid overload. Step 3: Limiting fluid intake (B) is crucial, but not the most important as fluid balance can be affected by various factors. Step 4: Increasing protein intake (D) is not recommended in advanced kidney disease due to potential strain on the kidneys.
Question 5 of 5
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen is essential to start the 24-hour collection accurately. By discarding the first void, the client ensures that the 24-hour collection will begin accurately. Choice A is incorrect because refrigeration is not necessary for a 24-hour urine collection. Choice B is incorrect because the collection should start after discarding the first morning void. Choice C is incorrect because keeping the urine on ice is not a standard practice for a 24-hour urine collection.