HESI RN
HESI RN CAT Exit Exam
1. An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?
- A. The emergency department is very busy at this time.
- B. I'll let you see the doctor next because you've waited so long.
- C. I'm doing the best I can for the sickest clients first.
- D. I understand you are frustrated with the wait time.
Correct answer: D
Rationale: The correct response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response acknowledges the client's emotions, shows empathy, and validates their feelings of frustration. Option A justifies the situation but does not address the client's emotional state. Option B is unfair to other patients and may not be based on urgency. Option C focuses on the nurse's actions rather than addressing the client's emotions, making it less effective than option D.
2. 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?
- A. When did your symptoms first begin?
- B. Can you describe the pain and how it feels?
- C. Do you have any changes in vision?
- D. Have you experienced any seizures?
Correct answer: D
Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.
3. In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client's B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take?
- A. Measure the client's oxygen saturation before taking further action
- B. Administer a PRN dose of nitroglycerin (Nitrostat)
- C. Administer the dose of furosemide as scheduled
- D. Hold the dose of furosemide until contacting the healthcare provider
Correct answer: C
Rationale: Administering the scheduled dose of furosemide is appropriate when a client with heart failure has an elevated BNP level. BNP elevation indicates fluid overload, and furosemide is a diuretic that helps in reducing excess fluid. Measuring the client's oxygen saturation (Choice A) is not directly related to addressing fluid overload. Administering nitroglycerin (Choice B) is not indicated for managing elevated BNP levels. Holding the furosemide dose (Choice D) would delay appropriate treatment for fluid overload.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct answer: C
Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.
5. The nurse is caring for a client who is receiving a continuous intravenous infusion of heparin. Which laboratory value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Partial thromboplastin time (PTT)
- D. Hemoglobin level
Correct answer: C
Rationale: The correct answer is C. Partial thromboplastin time (PTT) is the laboratory value that should be monitored to evaluate the effectiveness of heparin therapy. PTT reflects the intrinsic pathway of coagulation and is specifically sensitive to heparin's anticoagulant effects. Monitoring the PTT helps ensure that the client is within the therapeutic range to prevent clot formation without increasing the risk of bleeding. Choices A, B, and D are incorrect because while they are important laboratory values in other contexts, they are not specifically used to monitor the effectiveness of heparin therapy.
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