HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
Correct Answer: D
Rationale: The correct answer is D because maintaining fluid balance is crucial in acute glomerulonephritis to prevent complications like fluid overload or dehydration. A urine output of 1 to 2 ml/kg/hr indicates proper kidney function. A: Activity tolerance is important but not the top priority. B: Absence of skin breakdown is important but not directly related to the condition. C: Nutritional status is vital but not as urgent as fluid balance in this case.
Question 2 of 5
When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and encourages open communication. By acknowledging the client's question and offering to address any concerns, the nurse shows understanding and willingness to support the client emotionally. This response also promotes a therapeutic relationship and allows the client to express his feelings and fears. Choices B, C, and D are incorrect because they do not address the client's emotional needs or provide an opportunity for him to discuss his concerns about death. B and C are dismissive and do not encourage further discussion, while D minimizes the client's feelings and redirects the conversation away from his concerns.
Question 3 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) because with contractions every 2-3 minutes, the pump should infuse at a slow rate to prevent overstimulation of the uterus, which can lead to fetal distress. Infusing at a higher rate (B, C, D) could potentially increase contractions frequency and intensity, risking complications. It is crucial to maintain a balance to ensure safe labor progression.
Question 4 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 relieve itching without causing harm or compromising the cast. It allows for ventilation and cooling without introducing foreign objects that may cause skin irritation or damage. The other choices are incorrect because twisting the cast, shaking powder into it, or pushing a pencil under the cast can all potentially damage the cast or harm the child's skin. It is important to follow appropriate and safe methods to address itching while the cast is in place.
Question 5 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. The nurse should monitor the client's oral cavity regularly for signs of gum overgrowth. Bladder palpation (A) is not relevant to phenytoin side effects. Blood glucose monitoring (C) is typically not associated with phenytoin use. Auscultation of breath sounds (D) is not a specific assessment for phenytoin side effects.