HESI RN
HESI RN CAT Exit Exam Questions
Question 1 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 2 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 3 of 9
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
Correct Answer: D
Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications. Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process. Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process. Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.
Question 4 of 9
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
Correct Answer: C
Rationale: Rationale: 1. Heparin primarily affects the intrinsic pathway of coagulation. 2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy. 3. INR is more specific for monitoring heparin therapy compared to other options. 4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring. 5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
Question 5 of 9
The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?
Correct Answer: A
Rationale: The correct answer is A: Verify the client's blood type. This is crucial before administering PRBCs to prevent a potentially life-threatening transfusion reaction. Step 1: Check the blood type on the PRBCs label. Step 2: Verify the client's blood type against the label. Steps 3: Crossmatch the blood to ensure compatibility. Checking vital signs (C) is important but not the priority. Ensuring PRBCs are warm (B) is not necessary. Obtaining consent (D) is important but verifying blood type takes precedence to ensure safe transfusion.
Question 6 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 7 of 9
The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first is to apply a sterile saline dressing to the wound. This is because the client is experiencing evisceration, which is a medical emergency requiring immediate attention to prevent infection and further complications. By applying a sterile saline dressing, the nurse can protect the exposed bowel from contamination, maintain moisture, and promote healing. This action helps to reduce the risk of infection and provides a temporary barrier until further interventions can be implemented. Summary of Incorrect Choices: B: Notifying the healthcare provider is important, but immediate action to protect the exposed bowel is the priority. C: Administering pain medication does not address the primary concern of protecting the exposed bowel. D: Covering the wound with an abdominal binder does not provide the necessary protection and could potentially exacerbate the situation by applying pressure to the protruding bowel.
Question 8 of 9
A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.
Question 9 of 9
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
Correct Answer: A
Rationale: The correct answer is A: Blow cool air from a hair dryer under the cast. This method helps to relieve itching by providing airflow without causing damage to the cast or skin. It is safe and effective. Choice B: Twisting the cast back and forth may cause discomfort or injury to the child's arm. Choice C: Shaking powder into the cast can create a mess and may lead to skin irritation or infection. Choice D: Pushing a pencil under the cast edge can cause damage to the skin or lead to complications.