HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. 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 first action for the nurse to take in this scenario is to apply a sterile saline dressing to the wound. This is important to prevent infection and protect the exposed bowel. Covering the wound with a dressing helps maintain a sterile environment and prevents further contamination. Notifying the healthcare provider is important but should come after immediate intervention. Administering pain medication is not the priority in this situation as the main concern is the protruding bowel. Using an abdominal binder is not appropriate and could potentially worsen the condition. Therefore, applying a sterile saline dressing is the most appropriate initial action to address the client's immediate needs.
Question 2 of 5
A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
Correct Answer: B
Rationale: The correct answer is B: It prevents the blood from clotting. Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thus preventing blood from clotting excessively. This helps reduce the risk of thrombosis. Incorrect choices: A: It dissolves blood clots - Warfarin does not dissolve existing blood clots; it prevents new clots from forming. C: It thins the blood - While warfarin affects the clotting process, it does not actually thin the blood. D: It decreases the risk of infection - Warfarin is not used to decrease the risk of infection; its primary function is to prevent clot formation.
Question 3 of 5
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
Correct Answer: C
Rationale: Rationale: 1. Heparin primarily affects the intrinsic pathway of the coagulation cascade, monitored by PTT. 2. However, PTT can be influenced by various factors. 3. INR is a standardized measure of PT, more reliable for monitoring heparin therapy effectiveness. 4. Thus, INR is the most appropriate choice for monitoring heparin therapy. Other options are not as specific to heparin's action.
Question 4 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 5 of 5
The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
Correct Answer: A
Rationale: The correct answer is A: Administer an antiemetic before meals. Administering an antiemetic before meals helps prevent nausea in clients receiving chemotherapy by blocking the signals that trigger nausea and vomiting. By taking the antiemetic before meals, the client is less likely to experience nausea during or after eating. This proactive approach is effective in managing chemotherapy-induced nausea. Summary: - B: Providing frequent mouth care is important for oral hygiene but does not directly address the nausea caused by chemotherapy. - C: Encouraging small, frequent meals can help manage nausea, but administering an antiemetic before meals is a more targeted intervention. - D: Offering clear liquids may help with hydration but does not specifically address the nausea associated with chemotherapy.