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? This question is crucial because seizures can be a common symptom of a brain tumor. By asking about seizures, the nurse can gather important information about the client's condition and potential complications. Seizures can also indicate the location and size of the tumor. A: When did your symptoms first begin? This question is important, but seizures are more specific to brain tumor assessment. B: Can you describe the pain and how it feels? Pain can vary and may not always be present with a brain tumor. C: Do you have any changes in vision? Vision changes can occur but may not be as indicative of a brain tumor as seizures. In summary, asking about seizures is crucial for immediate assessment and management of a client with a brain tumor, as it can provide valuable insight into the client's condition.
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: 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 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 is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention. A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder. C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying. D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.
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 because chromosomal abnormalities are indeed the most common cause of early spontaneous abortions. These abnormalities can occur during fertilization or early cell division, leading to non-viable embryos. Choice B, incompetent cervix, typically causes late-term miscarriages. Choice C, infections, can contribute to miscarriages but are not the most common cause. Choice D, nutritional deficiencies, can impact pregnancy outcomes but are not the primary cause of early spontaneous abortions. In summary, the correct answer A is supported by the fact that chromosomal abnormalities are the leading cause of early spontaneous abortions, while the other choices are either more relevant to late-term miscarriages or less commonly associated with early pregnancy loss.
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. Daily weight is the most important data to assess fluid status in a client with pneumonia as weight changes can indicate fluid retention or loss, a crucial aspect in managing pneumonia. Skin turgor (B) is more indicative of hydration status, not overall fluid balance. Daily intake and output (A) is important but does not provide a direct measure of fluid status. Vital signs (D) are important for monitoring overall health but do not directly assess fluid status.