HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?
Correct Answer: A
Rationale: The correct answer is A. The highest priority is ensuring the safety of the client. By raising the side rails and placing the call bell within reach, the nurse can prevent falls and easily attend to any urgent needs. This intervention promotes the client's physical safety and ensures immediate assistance if necessary. Choice B is incorrect because pushing effectively is important but not the highest priority. Choice C is incorrect as timing and recording contractions are important but not as critical as ensuring immediate safety. Choice D is incorrect as positioning for anesthesia distribution is important but ensuring safety takes precedence.
Question 2 of 5
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? Seizures are a common complication of brain tumors and can provide critical information about the tumor's location and potential impact on the client's neurological function. Seizures can also indicate increased intracranial pressure. Asking about seizures helps assess the client's safety and neurological status. Rationales for incorrect choices: A: When did your symptoms first begin? While important, the onset of symptoms may not directly impact the client's immediate care needs as much as the presence of seizures. B: Can you describe the pain and how it feels? Pain can be a symptom of a brain tumor, but seizures are more indicative of neurological involvement. C: Do you have any changes in vision? Vision changes can occur with brain tumors, but seizures are a more urgent symptom that requires immediate attention.
Question 3 of 5
A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
Correct Answer: A
Rationale: Rationale: 1. Pelvic pain and dysmenorrhea could indicate gynecological issues. 2. Referring the client for a pelvic exam allows for a thorough assessment. 3. It helps identify any underlying conditions or infections. 4. Prompt treatment can alleviate symptoms and prevent complications. Summary: - Choice B is not appropriate as notifying parents is not the priority. - Choice C is important but not the immediate action needed. - Choice D is premature without assessing the client first.
Question 4 of 5
A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A. Placing the child in a mist tent is the first intervention because the child is presenting with symptoms of epiglottitis, a potentially life-threatening condition. The mist tent helps to humidify the airway and can provide relief for the child's breathing difficulties. It is important to maintain a patent airway and alleviate respiratory distress as a priority. Option B (obtain a sputum culture) is not the first priority as it does not address the immediate need to secure the airway and provide relief for the child's breathing difficulties. Option C (prepare for an emergent tracheostomy) is not the first intervention as it is an invasive procedure and should only be considered if other interventions fail to secure the airway. Option D (examine the child's oropharynx and report findings) is important but not the first priority in this scenario. Immediate intervention to address the respiratory distress is crucial.
Question 5 of 5
A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This technique involves applying manual pressure to the bladder to assist with urine elimination. It is a common method used in bladder training for clients with flaccid bladders to promote bladder emptying. Option A is incorrect because manual pressure should not be used to express urine as it can lead to complications. Option C is not appropriate for bladder training as it does not address bladder emptying. Option D is unrelated to bladder training and does not promote bladder emptying. The Crede maneuver is the most suitable option as it directly assists with bladder emptying in clients with flaccid bladders.