HESI RN
HESI RN CAT Exit Exam
1. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct answer: C
Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.
2. The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
- A. Notify the healthcare provider of the laboratory results
- B. Decrease the rate of the IV infusion
- C. Stop the infusion
- D. Administer sodium polystyrene sulfonate (Kayexalate)
Correct answer: C
Rationale: The correct action for the nurse to implement first is to stop the infusion. Stopping the infusion is crucial to prevent further potassium from being administered, which can exacerbate the client's hyperkalemia. Notifying the healthcare provider of the laboratory results (Choice A) can be done after taking immediate action to stop the infusion. Decreasing the rate of the IV infusion (Choice B) may not be sufficient to address the high potassium level quickly. Administering sodium polystyrene sulfonate (Kayexalate) (Choice D) is not the initial action for managing hyperkalemia; stopping the potassium infusion takes precedence.
3. 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.
4. A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a 'cottage cheese' appearance. Which prescription should the nurse implement first?
- A. Cleanse the perineum with warm soapy water 3 times per day
- B. Instill the first dose of nystatin (Mycostatin) vaginally per applicator
- C. Perform a glucose measurement using a capillary blood sample
- D. Obtain a blood specimen for sexually transmitted diseases (STDs)
Correct answer: B
Rationale: The correct answer is to instill the first dose of nystatin vaginally per applicator. Nystatin is an antifungal medication used to treat yeast infections, which are characterized by 'cottage cheese' discharge. Cleansing the perineum with warm soapy water may help with hygiene but does not address the underlying infection. Performing a glucose measurement is not relevant to the diagnosis of a vaginal infection. Obtaining a blood specimen for STDs is not the priority in this scenario as the symptoms described are indicative of a yeast infection.
5. A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client’s teaching plan?
- A. Avoid all forms of sugar
- B. Check blood glucose levels once a week
- C. Rotate insulin injection sites
- D. Monitor urine ketone levels
Correct answer: C
Rationale: Rotating insulin injection sites prevents lipodystrophy and ensures proper insulin absorption.
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