HESI RN
HESI RN CAT Exit Exam
1. 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?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct answer: A
Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.
2. The nurse is planning care for a client receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
- A. Administer an antiemetic before meals
- B. Provide frequent mouth care
- C. Encourage small, frequent meals
- D. Offer clear liquids
Correct answer: A
Rationale: Administering an antiemetic before meals is a crucial intervention to manage chemotherapy-induced nausea. Antiemetics help prevent or reduce nausea and vomiting associated with chemotherapy. Providing frequent mouth care (choice B) is important for managing oral mucositis but not specifically for nausea. Encouraging small, frequent meals (choice C) and offering clear liquids (choice D) are beneficial strategies for managing gastrointestinal side effects but may not be as effective in controlling nausea as administering antiemetics.
3. A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
- A. Refer the client to a healthcare provider for a pelvic examination
- B. Notify the parents that the client needs to be picked up from school
- C. Determine the date of the client's last menstrual period
- D. Ask the client to lie down for a pelvic examination
Correct answer: A
Rationale: The correct action the nurse should take first is to refer the client to a healthcare provider for a pelvic examination. This is important to rule out serious conditions that may be causing the abdominal pain and dysmenorrhea. While notifying the parents, determining the date of the client's last menstrual period, and asking the client to lie down for a pelvic examination could be necessary steps, the priority is to ensure a proper evaluation by a healthcare provider to address the client's presenting symptoms effectively.
4. A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?
- A. Impaired physical mobility
- B. Ineffective breathing pattern
- C. Impaired skin integrity
- D. Risk for infection
Correct answer: B
Rationale: Ineffective breathing pattern is the highest priority for a client in the late stage of ALS due to the significant risk of respiratory complications. As ALS progresses, the client may experience respiratory muscle weakness, leading to ineffective breathing patterns and potential respiratory failure. Addressing breathing difficulties promptly is crucial to ensure adequate oxygenation and prevent further complications. While impaired physical mobility, impaired skin integrity, and risk for infection are also important concerns in ALS care, they are secondary to addressing the client's breathing difficulties, which take precedence to maintain physiological stability and prevent life-threatening consequences.
5. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
- A. The depth of tissue destruction is minor
- B. Pain is interrupted due to nerve compression
- C. The full thickness burn has destroyed the nerves
- D. Second-degree burns are not usually painful
Correct answer: C
Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.
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