HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
Correct Answer: D
Rationale: The correct answer is D: Have you experienced any seizures? Seizures are a common complication of brain tumors and can provide critical information about the tumor's location and potential impact on the client's neurological function. Seizures can also indicate increased intracranial pressure. Asking about seizures helps assess the client's safety and neurological status. Rationales for incorrect choices: A: When did your symptoms first begin? While important, the onset of symptoms may not directly impact the client's immediate care needs as much as the presence of seizures. B: Can you describe the pain and how it feels? Pain can be a symptom of a brain tumor, but seizures are more indicative of neurological involvement. C: Do you have any changes in vision? Vision changes can occur with brain tumors, but seizures are a more urgent symptom that requires immediate attention.
Question 2 of 5
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. Placing the child in a mist tent is the first intervention because the child is presenting with symptoms of epiglottitis, a potentially life-threatening condition. The mist tent helps to humidify the airway and can provide relief for the child's breathing difficulties. It is important to maintain a patent airway and alleviate respiratory distress as a priority. Option B (obtain a sputum culture) is not the first priority as it does not address the immediate need to secure the airway and provide relief for the child's breathing difficulties. Option C (prepare for an emergent tracheostomy) is not the first intervention as it is an invasive procedure and should only be considered if other interventions fail to secure the airway. Option D (examine the child's oropharynx and report findings) is important but not the first priority in this scenario. Immediate intervention to address the respiratory distress is crucial.
Question 3 of 5
A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This technique involves applying manual pressure to the bladder to assist with urine elimination. It is a common method used in bladder training for clients with flaccid bladders to promote bladder emptying. Option A is incorrect because manual pressure should not be used to express urine as it can lead to complications. Option C is not appropriate for bladder training as it does not address bladder emptying. Option D is unrelated to bladder training and does not promote bladder emptying. The Crede maneuver is the most suitable option as it directly assists with bladder emptying in clients with flaccid bladders.
Question 4 of 5
A client who has had three spontaneous abortions is requesting information about possible causes. The nurse's response should be based on which information?
Correct Answer: A
Rationale: The correct answer is A. Chromosomal abnormalities are the most common cause of early spontaneous abortions. This is because genetic defects in the embryo are a significant factor in early pregnancy loss. Chromosomal abnormalities can prevent the embryo from developing properly, leading to spontaneous abortion. B: Incompetent cervix is a cause of late miscarriages, not early spontaneous abortions. C: Infections can cause spontaneous abortions, but they are not the most common cause. D: While nutritional deficiencies can impact pregnancy outcomes, chromosomal abnormalities are more prevalent in early spontaneous abortions.
Question 5 of 5
The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?
Correct Answer: C
Rationale: The correct answer is C: Daily weight. Monitoring daily weight is crucial in determining fluid status as sudden weight gain may indicate fluid retention, a common complication in pneumonia. Skin turgor (B) is more indicative of hydration status, not fluid balance. Daily intake and output (A) provide information on fluid intake and output but may not reflect overall fluid balance. Vital signs every 4 hours (D) are important but do not directly assess fluid status. Daily weight is the most direct and reliable indicator of fluid status, making it the most important data to obtain in this situation.