HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Apply a sterile saline dressing to the wound. This action is crucial to prevent infection and protect the exposed bowel. The first priority in this situation is to cover and protect the protruding bowel to prevent further damage and reduce the risk of infection. Applying a sterile saline dressing will maintain a clean environment, prevent contamination, and promote healing. It is important to address the wound before notifying the healthcare provider or administering pain medication. Summary: - A: Applying a sterile saline dressing is the immediate priority to protect the bowel and prevent infection. - B: Notifying the healthcare provider can be done after addressing the wound. - C: Administering pain medication is important but secondary to protecting the exposed bowel. - D: Covering the wound with an abdominal binder is not appropriate in this situation and may cause further harm.
Question 2 of 5
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 of 3 indicates severe neurological impairment, which is consistent with a comatose state and suggests a poor prognosis. The Glasgow Coma Scale ranges from 3 to 15, with lower scores indicating more severe impairment. A score of 3 is the lowest possible score, indicating deep unconsciousness. This client is not conscious, as indicated by the GCS score of 3, making choice C incorrect. Choice A is also incorrect as increased intracranial pressure may lead to altered consciousness but is not specifically indicated by a GCS score of 3. Choice B is incorrect as a GCS score of 3 indicates a very poor prognosis for recovery, not a good prognosis.
Question 3 of 5
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 first step because the description of the vaginal discharge as having a 'cottage cheese' appearance is indicative of a yeast infection, which is commonly caused by Candida species. Nystatin is an antifungal medication that targets Candida, making it the appropriate initial treatment for this type of infection. Cleansing the perineum with warm soapy water (choice A) may provide temporary relief but does not address the underlying infection. Performing a glucose measurement (choice C) is not relevant in this case unless diabetes is suspected. Obtaining a blood specimen for STD testing (choice D) is not necessary based on the symptoms described.
Question 4 of 5
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
Correct Answer: B
Rationale: The correct answer is B, a 35-year-old with lupus erythematosus, because the antepartal unit specializes in caring for pregnant women. Clients with chronic hepatitis B, rubella, and herpes lesions of the vulva do not require transfer to the antepartal unit as their conditions are not directly related to pregnancy. Lupus erythematosus, however, is a systemic autoimmune disease that can have implications for pregnancy outcomes, such as increased risk of preterm birth and preeclampsia. Therefore, transferring the client with lupus to the antepartal unit ensures specialized care and monitoring during pregnancy.
Question 5 of 5
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B because it is important for the client to maintain the appropriate timing of taking the Zithromax for optimal effectiveness. By instructing the client to eat breakfast and then take the Zithromax two hours after eating, the nurse ensures that the medication is still absorbed effectively without causing any potential GI upset. Option A is incorrect because waiting for a new breakfast tray is unnecessary and delays medication administration. Option C is incorrect as skipping a dose may lead to suboptimal treatment outcomes. Option D is incorrect as providing an antacid is not indicated in this situation and may not address the issue of timing the Zithromax correctly.