HESI RN CAT Exit Exam 1

HESI RN

1. In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

A. Pink lips and tongue with cyanotic hands and feet
B. Respiration rate of 40 and heart rate of 144
C. Centralized cyanosis and tachycardia when crying
D. Desquamation from areas of cracked, parchment-like skin

Correct answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

2. The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement?

A. Maintain possession of the evidence collection kit at all times until submitted to law enforcement
B. Provide discharge instructions for prophylactic antibiotics, pregnancy, and HIV prevention medication
C. Document the characteristics of the various sites of sample collection
D. Assist the client with toileting, hygiene, and dressing with clean clothes

Correct answer: A

Rationale: Maintaining possession of the evidence collection kit at all times until submitted to law enforcement is crucial to ensure the integrity of the chain of custody. This step helps prevent tampering or contamination of the evidence, which is vital for the legal process. Providing discharge instructions for medications, documenting sample characteristics, and assisting the client with personal care are important aspects of care but not the immediate priority when handling forensic evidence in a sexual assault case.

3. A 24-year-old female client who has a history of rheumatoid arthritis (RA) is taking ibuprofen (Motrin) for pain relief. Which information should the nurse provide the client about taking this medication?

A. Take the medication with meals
B. Take the medication with an antacid
C. Report any changes in stool color to your healthcare provider
D. Avoid taking aspirin while using this medication

Correct answer: C

Rationale: The correct answer is to instruct the client to report any changes in stool color to the healthcare provider. This is important because changes in stool color can indicate gastrointestinal bleeding, a serious side effect of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Choice A is incorrect because while taking ibuprofen with meals can help reduce stomach upset, it is not the most crucial information to provide. Choice B is incorrect as taking ibuprofen with an antacid is not a standard recommendation. Choice D is also incorrect because while ibuprofen and aspirin are both NSAIDs, they can be taken together under certain circumstances, but it's important to be cautious and follow healthcare provider recommendations.

4. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?

A. Find supplies to put a dressing on the client's wrists
B. Take the client to a room for supervision by staff
C. Call the healthcare provider to report the client's behavior
D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.

5. A male client admitted three days ago with respiratory failure is intubated, and 40% oxygen per facemask is initiated. Currently, his temperature is 99Â°F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?

A. Exhibits adequate tissue perfusion
B. Remains free of injury
C. Remains free of infection
D. Maintains effective breathing pattern

Correct answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.