HESI RN
HESI RN CAT Exit Exam
1. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
- A. Weight gain of 2 pounds in 24 hours
- B. Presence of a cough
- C. Edema in the lower extremities
- D. Shortness of breath
Correct answer: D
Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.
2. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
- A. Avoiding the administration of high levels of oxygen for extended periods.
- B. Administering a sedative at bedtime to slow the client's respiratory rate.
- C. Removing the nasal cannula during the night to prevent oxygen buildup.
- D. Running oxygen through a hydration source prior to administration.
Correct answer: A
Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.
3. 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?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct answer: A
Rationale: The correct answer is A: 'Blow cool air from a hairdryer under the cast.' Blowing cool air can help relieve itching without damaging the cast or causing injury. Choice B, twisting the cast back and forth, can lead to discomfort, skin irritation, or even injury. Choice C, shaking powder into the cast, can create a mess, increase the risk of skin issues, and interfere with proper healing. Choice D, pushing a pencil under the cast edge, is dangerous as it can cause injury to the child's skin or the underlying tissues. Therefore, the safest and most effective option to relieve itching under the cast is to blow cool air from a hair dryer.
4. The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct answer: D
Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.
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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