HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
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 2 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 3 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 4 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 5 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.