hesi rn cat exit exam HESI RN CAT Exit Exam - Nursing Elites
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Nursing Elites

HESI RN

HESI RN CAT Exit Exam

1. The nurse is caring for a laboring 22-year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority?

Correct answer: A

Rationale: The highest priority nursing intervention for a laboring client following administration of regional anesthesia is to ensure safety by raising the side rails and placing the call bell within reach. This is crucial to prevent falls and to ensure that the client can call for assistance if needed. Teaching the client how to push effectively (Choice B) is important but not the highest priority at this moment. Timing and recording uterine contractions (Choice C) are essential but not as immediate as ensuring safety post-anesthesia. Positioning the client for proper distribution of anesthesia (Choice D) is important but ensuring immediate safety takes precedence in this situation.

2. The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?

Correct answer: D

Rationale: The correct answer is D. A serum calcium level of 7.8 mg/dL requires immediate intervention due to the risk of hypocalcemia. Hypocalcemia can lead to serious complications such as tetany, seizures, and cardiac arrhythmias. The other laboratory findings are within normal limits or slightly elevated, which do not pose an immediate threat to the client's health in this scenario.

3. The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?

Correct answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). While INR is commonly used to monitor the effectiveness of warfarin therapy, in the case of heparin therapy, the Partial Thromboplastin Time (PTT) is the preferred test. Choice A, Prothrombin Time (PT), measures the activity of the extrinsic pathway of coagulation and is not the best choice for monitoring heparin therapy. Choice D, Activated Partial Thromboplastin Time (aPTT), is similar to PTT and is used to monitor heparin therapy, but PTT is the more specific test. Therefore, monitoring PTT is crucial in determining the effectiveness and safety of heparin therapy.

4. A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

Correct answer: D

Rationale: The correct answer is 'D. Breath sounds.' When a client receiving amlodipine develops edema, it is crucial to assess for potential heart failure, a side effect of the medication. Checking breath sounds helps in identifying any signs of pulmonary edema, a severe complication of heart failure. Choices A, B, and C are less relevant in this context. Bladder distention could be associated with urinary issues, serum albumin level with malnutrition or liver disease, and abdominal girth with gastrointestinal problems, none of which directly relate to the potential heart failure induced by amlodipine.

5. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?

Correct answer: D

Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.

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