HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A: Verify the client's blood type. This is crucial before administering PRBCs to prevent a potentially life-threatening transfusion reaction. Step 1: Check the blood type on the PRBCs label. Step 2: Verify the client's blood type against the label. Steps 3: Crossmatch the blood to ensure compatibility. Checking vital signs (C) is important but not the priority. Ensuring PRBCs are warm (B) is not necessary. Obtaining consent (D) is important but verifying blood type takes precedence to ensure safe transfusion.
Question 2 of 5
A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
Correct Answer: D
Rationale: The correct answer is D: Shortness of breath. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress. A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath. B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath. C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.
Question 3 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Check the client's oxygen saturation level. This is the first action the nurse should take to assess the effectiveness of the current oxygen therapy and determine the client's oxygenation status. A: Increasing the oxygen flow rate without assessing the client's oxygen saturation level may lead to potential oxygen toxicity. B: Instructing the client to breathe deeply and cough may not address the underlying issue of hypoxemia. D: Placing the client in a high-Fowler's position may help with breathing but does not address the immediate concern of the client's difficulty breathing. Checking the oxygen saturation level provides crucial information for appropriate interventions.
Question 4 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. With heparin being an anticoagulant, monitoring PTT helps ensure the client is within the therapeutic range to prevent clot formation. A - Platelet count assesses risk of bleeding, not heparin effectiveness. B - Prothrombin time (PT) is used to monitor warfarin therapy, not heparin. D - Hemoglobin level monitors for anemia, not heparin effectiveness.
Question 5 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 action for the nurse to take first is to apply a sterile saline dressing to the wound (Choice A). This is because the client's situation suggests an incisional dehiscence, which is a surgical complication requiring immediate attention to prevent infection and further complications. Applying a sterile saline dressing helps protect the exposed bowel from contamination and dehydration. Notifying the healthcare provider (Choice B) is important, but immediate wound care is the priority to prevent complications. Administering pain medication (Choice C) can wait until after the wound is properly dressed and assessed. Covering the wound with an abdominal binder (Choice D) is not appropriate in this situation as it does not address the urgent need to protect the exposed bowel and prevent infection.