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. The nurse should monitor the client's oral cavity regularly for signs of gum overgrowth. Bladder palpation (A) is not relevant to phenytoin side effects. Blood glucose monitoring (C) is typically not associated with phenytoin use. Auscultation of breath sounds (D) is not a specific assessment 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 because a patient whose discharge has been delayed due to a postoperative infection can benefit from the skills of a newly graduated practical nurse without requiring constant supervision. This patient likely needs routine wound care, medication administration, and monitoring, tasks that align with the competencies of a practical nurse. Assigning this patient allows the new nurse to practice skills independently while still providing valuable care. Choices B, C, and D are incorrect because they involve patients with complex needs that require a higher level of expertise and supervision. Patients with poorly controlled diabetes on insulin, head injury requiring frequent assessments, and IV heparin administration need closer monitoring and specialized care that may exceed the scope of practice for a new graduate without adequate supervision. Assigning these patients to the new nurse could compromise patient safety and quality of care.
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. Oxygen toxicity can occur with prolonged exposure to high levels of oxygen. 2. Administering high levels of oxygen for extended periods increases the risk of oxygen toxicity. 3. Therefore, avoiding the administration of high levels of oxygen for extended periods is effective in preventing oxygen toxicity. Summary: - Choice A is correct because it addresses the root cause of oxygen toxicity by avoiding prolonged exposure to high levels of oxygen. - Choices B, C, and D are incorrect as they do not directly address the prevention of oxygen toxicity and may even pose risks to the client's respiratory status.
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: The correct answer is C: Elevated urine specific gravity. In a dehydrated child, the kidneys conserve water, leading to concentrated urine with an elevated specific gravity. This indicates the body's attempt to retain fluid. The other choices are incorrect because: A: Occult blood in the stool indicates a possible gastrointestinal bleed, not dehydration. B: Abdominal distention can be caused by various factors, including gas or fecal impaction, but is not a specific sign of dehydration. D: Hyperactive bowel sounds can be present in various gastrointestinal conditions but are not specific to 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: The child is experiencing altered nutrition due to anorexia, nausea, and vomiting from chemotherapy. Step 2: Allowing the child to eat foods desired and tolerated promotes intake and prevents further nutritional deficits. Step 3: Restricting foods from fast food restaurants may limit the child's choices and lead to decreased intake. Step 4: Recommending eating the same foods as siblings may not consider the child's specific needs and preferences. Step 5: Encouraging large portions at every meal may overwhelm the child and worsen symptoms.