HESI RN
HESI RN CAT Exit Exam Questions
Question 1 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 action is to measure the length of the apneic periods. By measuring the length, the nurse can gather crucial information about the severity and frequency of the Cheyne-Stokes respirations. This data can help in determining the appropriate interventions and monitoring the client's condition. Elevating the head of the bed may help with breathing, but it does not directly address the apneic periods. Auscultating breath sounds and suctioning the oropharynx are not the priority actions in this situation.
Question 2 of 5
A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
Correct Answer: A
Rationale: The correct answer is A: Ineffective airway clearance. Postoperative clients are at risk for respiratory complications such as atelectasis due to anesthesia effects and decreased mobility. In this case, a flank incision for ureter lithotomy may cause pain, impairing deep breathing and coughing, leading to ineffective airway clearance. Priority is given to airway management to prevent respiratory complications. Altered nutrition (B), fluid volume excess (C), and activity intolerance (D) are important but not as immediate as ensuring adequate oxygenation and preventing respiratory compromise.
Question 3 of 5
When the nurse enters the room to change the dressing of a male client with cancer, he asks, 'Have you ever been with someone when they died?' What is the nurse's best response to him?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates empathy and encourages open communication. By acknowledging the client's question and offering to address any concerns, the nurse shows understanding and willingness to support the client emotionally. This response also promotes a therapeutic relationship and allows the client to express his feelings and fears. Choices B, C, and D are incorrect because they do not address the client's emotional needs or provide an opportunity for him to discuss his concerns about death. B and C are dismissive and do not encourage further discussion, while D minimizes the client's feelings and redirects the conversation away from his concerns.
Question 4 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 5 of 5
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 relieve itching without causing harm or compromising the cast. It allows for ventilation and cooling without introducing foreign objects that may cause skin irritation or damage. The other choices are incorrect because twisting the cast, shaking powder into it, or pushing a pencil under the cast can all potentially damage the cast or harm the child's skin. It is important to follow appropriate and safe methods to address itching while the cast is in place.