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) because with contractions every 2-3 minutes, the pump should infuse at a slow rate to prevent overstimulation of the uterus, which can lead to fetal distress. Infusing at a higher rate (B, C, D) could potentially increase contractions frequency and intensity, risking complications. It is crucial to maintain a balance to ensure safe labor progression.
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. 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 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 important because using a large, deep muscle mass helps distribute the medication effectively and reduces the risk of tissue irritation and nerve damage. It also allows for better absorption of the medication. Option A is incorrect because instilling the medication quickly can cause pain and tissue damage. Option B is incorrect as inserting the needle slowly does not necessarily impact the effectiveness of the injection. Option D is incorrect as using a short, small gauge needle may not reach the desired muscle depth for optimal medication absorption. Therefore, selecting a large, deep muscle mass is the best intervention for administering an intramuscular injection containing a painful medication.
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 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 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. 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.