HESI RN
HESI RN CAT Exit Exam Questions
Question 1 of 5
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
Correct Answer: D
Rationale: The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up. A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned. B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers. C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension. In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.
Question 2 of 5
The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
Correct Answer: D
Rationale: The correct answer is D: Combine several legumes and grains such as beans and rice to form complete proteins. This is the best option because a lacto-vegetarian diet excludes meat but includes dairy products. Legumes and grains complement each other in terms of amino acid profiles, allowing the individual to obtain all essential amino acids needed for protein synthesis. This combination ensures the client gets adequate protein intake necessary for red blood cell production without consuming meat. A: Drinking whole milk instead of skim milk does not enhance amino acid production. Skim milk contains the same amino acids as whole milk. B: Taking vitamin K does not enhance red blood cell production. Iron is the key nutrient needed for red blood cell production. C: Increasing dark yellow vegetables such as carrots does not provide a significant amount of iron to fortify iron stores compared to legumes and grains.
Question 3 of 5
A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?
Correct Answer: D
Rationale: The correct answer is D (Breath sounds). Pitting edema is a common side effect of amlodipine due to vasodilation. It can also lead to pulmonary edema, causing shortness of breath and crackles on auscultation. Therefore, assessing breath sounds is crucial to detect any signs of fluid overload and potential pulmonary complications. Bladder distention (A) is not directly related to the client's current symptoms. Serum albumin level (B) may indicate protein status but is not immediately necessary in this case. Abdominal girth (C) is more indicative of ascites or abdominal distension, not directly related to the client's edema and possible pulmonary complications.
Question 4 of 5
While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
Correct Answer: C
Rationale: The correct answer is C: Measure the length of the apneic periods. This action is crucial in assessing the severity of Cheyne-Stokes respirations and guiding further interventions. By measuring the length of apneic periods, the nurse can determine the duration of respiratory pauses and their impact on oxygenation. This information helps in deciding the appropriate treatment, such as administering supplemental oxygen or notifying the healthcare provider. Elevating the head of the bed (choice A) can help with breathing but does not address the root cause. Auscultating breath sounds (choice B) is important but does not directly address the apneic periods. Suctioning the oropharynx (choice D) is not indicated unless there is an airway obstruction.
Question 5 of 5
The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?
Correct Answer: D
Rationale: The correct answer is D. In acute glomerulonephritis, the kidneys are inflamed, affecting fluid balance. Monitoring urine output of 1 to 2 ml/kg/hr is crucial to assess kidney function and prevent fluid overload or dehydration. This is the priority outcome as it directly reflects kidney function and overall fluid balance. A: Activity tolerance is important but not the priority in acute glomerulonephritis. B: Absence of skin breakdown is important for overall health but not directly related to the condition. C: Nutritional status is important, but fluid balance takes precedence in managing acute glomerulonephritis. In summary, maintaining fluid balance is crucial in managing acute glomerulonephritis as it directly reflects kidney function, while the other options are important but not the priority in this scenario.