HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?
Correct Answer: C
Rationale: The correct answer is C: Daily weight. Daily weight is the most important data to assess fluid status in a client with pneumonia as weight changes can indicate fluid retention or loss, a crucial aspect in managing pneumonia. Skin turgor (B) is more indicative of hydration status, not overall fluid balance. Daily intake and output (A) is important but does not provide a direct measure of fluid status. Vital signs (D) are important for monitoring overall health but do not directly assess fluid status.
Question 2 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 a high serum potassium level indicate the client is at risk for hyperkalemia, which can be exacerbated by the potassium chloride infusion. Stopping the infusion is crucial to prevent further elevation of potassium levels and potential cardiac complications. Choice A (Notify the healthcare provider) is not the first action as immediate intervention is needed to prevent harm. Choice B (Decrease the rate of the IV infusion) is not sufficient to address the immediate risk of hyperkalemia. Choice D (Administer sodium polystyrene sulfonate) is not appropriate as the first action and should only be considered after stabilizing the client's condition.
Question 3 of 5
The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
Correct Answer: D
Rationale: The correct answer is D: Serum calcium of 7.8 mg/dL. This finding indicates hypocalcemia, which can lead to life-threatening cardiac arrhythmias. Low calcium levels can be caused by TPN administration or poor calcium absorption following bowel resection. Immediate intervention may include administering IV calcium gluconate. A: Blood glucose of 140 mg/dL is within the normal range and not an immediate concern. B: White blood cell count of 8000/mm³ is within the normal range and does not require immediate intervention. C: Serum potassium of 3.8 mEq/L is within the normal range and does not pose an immediate threat.
Question 4 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 may indicate a potential serious issue such as kidney problems or infection in the elderly. The kidneys are located in the lower back region, so pain in this area could be a sign of kidney dysfunction. The nurse should report this finding to the healthcare provider immediately for further evaluation and intervention. Choice A is incorrect because decreased urine output can be a common issue in older adults and may not always indicate a serious problem. Choice B is incorrect as loss of appetite can have various causes and may not be as urgent as lower back pain. Choice D is also incorrect as a persistent cough can have multiple causes, but it is not as concerning as potential kidney issues indicated by lower back pain in an older client.
Question 5 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 drug, and its purpose is to control seizures. Seizure precautions aim to prevent injury during a seizure, ensuring the client's safety. Monitoring serum calcium levels (A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (B) is not a priority unless there are specific cardiac concerns. Encouraging a low-protein diet (D) is not necessary for phenytoin therapy.