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. Monitoring daily weight is crucial in determining fluid status as sudden weight gain may indicate fluid retention, a common complication in pneumonia. Skin turgor (B) is more indicative of hydration status, not fluid balance. Daily intake and output (A) provide information on fluid intake and output but may not reflect overall fluid balance. Vital signs every 4 hours (D) are important but do not directly assess fluid status. Daily weight is the most direct and reliable indicator of fluid status, making it the most important data to obtain in this situation.
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 high serum potassium level indicate potential renal impairment or potassium retention, which can lead to hyperkalemia. Stopping the infusion is crucial to prevent further potassium buildup and worsening kidney function. Notifying the healthcare provider (Choice A) can be done after stopping the infusion. Decreasing the infusion rate (Choice B) may not be sufficient to address the immediate risk of hyperkalemia. Administering sodium polystyrene sulfonate (Kayexalate) (Choice D) is a treatment for hyperkalemia but should not be the initial action in this situation.
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 serious complications like tetany or seizures. Hypocalcemia is a common complication after bowel resection due to impaired absorption. Immediate intervention is crucial to prevent further complications. A: Blood glucose of 140 mg/dL is within normal range and does not require immediate intervention. B: White blood cell count of 8000/mm³ is within normal range and does not require immediate intervention. C: Serum potassium of 3.8 mEq/L is within normal range and does not require immediate intervention.
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 in an older client can be indicative of a serious underlying issue such as a kidney infection, kidney stones, or spinal issues. The nurse should report this finding to the healthcare provider promptly for further evaluation and intervention to prevent potential complications. Choice A is not as urgent as it may indicate dehydration or renal issues, but it is not as critical as the potential issues related to back pain. Choice B, loss of appetite, is important but may not be as urgent as potential kidney or spinal issues. Choice D, a persistent cough, is also important but may not be as immediately concerning as the possibility of a serious condition related to 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 medication used for seizure control. Seizure precautions aim to prevent injury during a seizure by ensuring a safe environment for the client. Monitoring serum calcium levels (choice A) is not directly related to phenytoin therapy. Obtaining a baseline electrocardiogram (choice B) is not specifically indicated for clients on phenytoin. Encouraging a low-protein diet (choice D) is not a priority in the care of a client receiving phenytoin for seizure control.