HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
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 5
The nurse is making assignments for a new graduate from a practical nursing program who is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign to this newly graduated practical nurse?
Correct Answer: A
Rationale: The correct answer is A: Whose discharge has been delayed because of a postoperative infection. This assignment is the best choice for the new graduate nurse because a client whose discharge has been delayed due to a postoperative infection is likely stable and requires minimal immediate interventions. This client would benefit from the new nurse's routine care and monitoring skills, allowing the nurse to focus on completing tasks efficiently. Option B: With poorly controlled type 2 diabetes who is on a sliding scale for insulin administration requires close monitoring and frequent adjustments in insulin dosages, which may be challenging for a new nurse without adequate supervision. Option C: Newly admitted with a head injury who requires frequent assessments demands critical thinking skills and quick decision-making abilities, which may overwhelm a new nurse who lacks experience in handling such cases. Option D: Receiving IV heparin that is regulated based on protocol involves complex medication management and monitoring for potential complications, which may be beyond the scope of a new nurse's comfort level without proper guidance.
Question 3 of 5
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 4 of 5
A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?
Correct Answer: C
Rationale: Step 1: Elevated urine specific gravity indicates increased concentration of urine, a sign of dehydration. Step 2: In dehydration, the body conserves water, leading to concentrated urine. Step 3: The child's symptoms (increased stools, liquid consistency, fever, vomiting) suggest dehydration. Step 4: Other choices (A: occult blood, B: distention, D: hyperactive bowel sounds) are not specific to dehydration. Summary: Elevated urine specific gravity is key as it directly reflects dehydration, unlike the other choices which are not specific indicators of dehydration.
Question 5 of 5
A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, altered nutrition, less than body requirements related to anorexia, nausea, vomiting is identified. Which intervention should the nurse include in this child's plan of care?
Correct Answer: A
Rationale: Step 1: A child with Leukemia undergoing chemotherapy often experiences anorexia, nausea, and vomiting, leading to altered nutrition. Step 2: Allowing the child to eat foods desired and tolerated promotes intake, ensuring adequate nutrition. Step 3: Restricting foods (Choice B) can exacerbate the child's already limited intake and lead to nutritional deficiencies. Step 4: Recommending the same foods as siblings (Choice C) may not address the specific needs of the child undergoing chemotherapy. Step 5: Encouraging large portions of food (Choice D) may overwhelm the child and worsen their symptoms.