HESI RN
HESI RN CAT Exit Exam
1. The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct answer: A
Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps to cover and protect the exposed bowel, preventing infection and maintaining a moist environment for wound healing. Option B, notifying the healthcare provider, is important but should come after addressing the immediate need of covering the wound. Administering pain medication (option C) and covering the wound with an abdominal binder (option D) are not appropriate initial actions for this situation.
2. 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?
- A. Daily intake and output
- B. Skin turgor
- C. Daily weight
- D. Vital signs every 4 hours
Correct answer: C
Rationale: Daily weight is the most important data for the nurse to obtain in determining the client's fluid status in this scenario. During febrile episodes, assessing daily weight is crucial as it can indicate fluid retention or loss. While monitoring intake and output is important for assessing fluid balance, daily weight provides a more comprehensive picture of fluid status over time. Skin turgor is more indicative of hydration status than overall fluid status, and vital signs, although essential, do not directly assess fluid status as effectively as daily weight.
3. 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?
- A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
- B. Take vitamin K 10mg PO daily to enhance production of red blood cells
- C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
- D. Combine several legumes and grains such as beans and rice to form complete proteins
Correct answer: D
Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.
4. A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?
- A. It dissolves blood clots
- B. It prevents the blood from clotting
- C. It thins the blood
- D. It decreases the risk of infection
Correct answer: B
Rationale: The correct answer is B: 'It prevents the blood from clotting.' Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thereby preventing the formation of blood clots. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones from forming. Choice C is partially correct but not as specific as choice B in explaining how warfarin works. Choice D is unrelated to the mechanism of action of warfarin and is incorrect.
5. Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
- A. Wear long-sleeved clothing when outdoors
- B. Report the onset of sore throat
- C. Eat plenty of potassium-rich food
- D. Change the position slowly
Correct answer: D
Rationale: The correct instruction for an elderly client taking both an ACE inhibitor and a calcium channel blocker is to change positions slowly. Both medications can lead to orthostatic hypotension, a sudden drop in blood pressure when changing positions, which can increase the risk of falls. Instructing the client to change positions slowly helps prevent falls. Wearing long-sleeved clothing when outdoors does not directly relate to the medication combination. Reporting the onset of a sore throat is important for monitoring potential side effects but is not specific to these medications. While potassium levels should be monitored with ACE inhibitors, eating plenty of potassium-rich foods without guidance can lead to hyperkalemia, a potential side effect of ACE inhibitors.
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