HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 9
What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?
Correct Answer: B
Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring for phenytoin side effects.
Question 2 of 9
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
Correct Answer: D
Rationale: The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up. A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned. B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers. C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension. In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.
Question 3 of 9
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
Question 4 of 9
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: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
Question 5 of 9
Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. High levels of oxygen over a prolonged period can lead to oxygen toxicity. 2. Oxygen toxicity can cause lung damage and respiratory distress. 3. To prevent oxygen toxicity, it is crucial to monitor and limit the duration and amount of oxygen administered. 4. Therefore, avoiding the administration of high levels of oxygen for extended periods is the most effective intervention to prevent oxygen toxicity. Summary of other choices: B: Administering a sedative does not address the root cause of oxygen toxicity and can mask symptoms. C: Removing the nasal cannula at night can lead to hypoxia and is not a safe practice. D: Running oxygen through a hydration source does not prevent oxygen toxicity and is not a recognized intervention.
Question 6 of 9
A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement?
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to eat his breakfast and take the Zithromax two hours after eating. This is the correct action because azithromycin is best absorbed when taken on an empty stomach, but if the client has already eaten, it is recommended to wait at least 2 hours after a meal before taking it. This ensures optimal absorption and effectiveness of the medication. Choice A is incorrect because it does not address the timing issue of taking azithromycin on an empty stomach. Choice C is incorrect as skipping a dose of an antibiotic can lead to treatment failure. Choice D is incorrect as antacids can interfere with the absorption of azithromycin and should not be taken together.
Question 7 of 9
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
Correct Answer: A
Rationale: The correct answer is A: 5 ml/hour. To calculate the infusion rate, you need to divide the total amount infused by the total time in hours. Given contractions every 2-3 minutes, which is equivalent to 20-30 contractions per hour, the pump should infuse at 5 ml/hour to ensure proper medication delivery. Choices B, C, and D are incorrect because they do not correspond to the frequency of contractions and may lead to under or overmedication.
Question 8 of 9
The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?
Correct Answer: C
Rationale: Rationale: Choice C is correct because sudden weight gain can indicate fluid retention, a common complication in chronic kidney disease. This can lead to serious issues like heart failure. Monitoring weight daily (A) is important, but specifically reporting significant gains promptly (C) is crucial. Limiting fluid intake (B) is important, but not the top priority. Increasing protein intake (D) may worsen kidney function, so it's not recommended.
Question 9 of 9
When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C: Select a large, deep muscle mass. This is because using a large, deep muscle mass ensures proper absorption and distribution of the medication, reducing the risk of tissue damage or irritation. Rationale: 1. Instilling the medication quickly (Choice A) can cause discomfort and increase the risk of tissue trauma. 2. Inserting the needle slowly (Choice B) can also lead to pain and discomfort for the patient. 3. Using a short, small gauge needle (Choice D) may not reach the deep muscle mass and can cause inadequate absorption of the medication. In summary, selecting a large, deep muscle mass ensures optimal medication delivery and minimizes discomfort and tissue damage compared to the other choices.