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: Step 1: Verify the client's blood type is crucial to ensure compatibility and prevent adverse reactions such as hemolytic transfusion reactions. Step 2: Ensuring PRBCs are warm is important but not the most critical as they can be warmed before administration. Step 3: Checking vital signs is important but not the priority compared to verifying blood type for safe transfusion. Step 4: Obtaining consent is essential but does not address the immediate safety concern of blood type compatibility.
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. It is a concerning sign in a client with CHF and fluid volume overload, indicating possible worsening of pulmonary congestion. Shortness of breath can be a result of fluid accumulation in the lungs, leading to respiratory distress. Reporting this finding promptly to the healthcare provider is crucial for timely intervention to prevent further complications. A: Weight gain of 2 pounds in 24 hours could be an early sign of fluid retention, but shortness of breath is a more critical finding in this scenario. B: Presence of a cough may indicate pulmonary congestion, but shortness of breath is a more severe symptom that requires immediate attention. C: Edema in the lower extremities is a common manifestation of fluid overload but may not be as urgent as shortness of breath in indicating worsening condition.
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: Step 1: Check the client's oxygen saturation level to assess the effectiveness of oxygen therapy. Step 2: If oxygen saturation is low, adjust oxygen flow rate accordingly. Step 3: If oxygen saturation is adequate, further assess the client's condition. Step 4: Instructing deep breathing and coughing may help with airway clearance but should not be the first action. Step 5: Placing the client in high-Fowler's position may aid breathing but does not address the immediate need to assess oxygen saturation level.
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. 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 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 first action for the nurse to take in this scenario is to apply a sterile saline dressing to the wound. This is important to prevent infection and protect the exposed bowel. Covering the wound with a dressing helps maintain a sterile environment and prevents further contamination. Notifying the healthcare provider is important but should come after immediate intervention. Administering pain medication is not the priority in this situation as the main concern is the protruding bowel. Using an abdominal binder is not appropriate and could potentially worsen the condition. Therefore, applying a sterile saline dressing is the most appropriate initial action to address the client's immediate needs.