HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
Correct Answer: C
Rationale: The correct answer is C: Partial thromboplastin time (PTT). PTT measures the effectiveness of heparin therapy by assessing the clotting time. Monitoring PTT helps ensure the client is within the therapeutic range for anticoagulation. Platelet count (A) monitors for thrombocytopenia, not heparin effectiveness. Prothrombin time (PT) (B) primarily assesses warfarin therapy. Hemoglobin level (D) monitors for anemia, not heparin effectiveness.
Question 2 of 5
A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. The client is experiencing hypoglycemia with a blood glucose level of 60 mg/dl. 2. Administering 15 grams of carbohydrate will help raise the blood glucose level quickly. 3. Carbohydrates are the preferred treatment for hypoglycemia in clients with diabetes. 4. Glucagon injection is used for severe hypoglycemia when the client is unconscious. 5. Providing a snack with protein is not ideal for immediate treatment of hypoglycemia. 6. Encouraging the client to rest is not a priority over addressing the low blood glucose level.
Question 3 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 4 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 5 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.