HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
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.
Question 2 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 3 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 4 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.
Question 5 of 5
In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
Correct Answer: C
Rationale: The correct action is to administer the dose of furosemide as scheduled (Choice C) because an elevated BNP level indicates increased fluid volume and pressure in the heart. Furosemide is a diuretic that helps reduce fluid overload in heart failure patients, which can alleviate symptoms and improve cardiac function. Holding the dose (Choice D) could delay necessary treatment, potentially worsening the patient's condition. Measuring oxygen saturation (Choice A) is important but not the immediate priority in this situation. Administering nitroglycerin (Choice B) is not appropriate as it is used for chest pain related to angina, not for treating elevated BNP levels in heart failure.