HESI RN
HESI RN CAT Exit Exam 1
1. A nurse is assessing the learning needs of a client who is diagnosed with Addison's disease. Which statement indicates that the client needs further teaching?
- A. I should take my medications daily to replace necessary hormones
- B. I need to eat a diet high in protein and carbohydrates
- C. I should avoid drinking fluids with caffeine
- D. I should notify my healthcare provider if I start feeling dizzy
Correct answer: B
Rationale: The correct answer is B. A diet high in protein and carbohydrates is not specifically required for Addison's disease. The focus should be on maintaining a balanced diet that is rich in fruits, vegetables, whole grains, and adequate protein sources. Choice A is correct as adherence to medication therapy is crucial in managing Addison's disease. Choice C is correct as caffeine can exacerbate symptoms of Addison's disease. Choice D is correct as dizziness can be a sign of adrenal crisis in Addison's disease, and prompt notification of healthcare providers is essential.
2. 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.
3. The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?
- A. Assess the client's oxygen saturation level
- B. Teach the client pursed-lip breathing techniques
- C. Determine the client's history of lung disease
- D. Obtain an arterial blood gas sample
Correct answer: A
Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.
4. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?
- A. I cannot give you this medication until you calm down.
- B. This shot will help relieve the pain in your feet.
- C. Would you prefer to learn to administer your own shot?
- D. You will feel calmer and less jittery after this shot.
Correct answer: B
Rationale: Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication. Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses. Choice A focuses on the client's behavior rather than the therapeutic effect of the injection. Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation. Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.
5. 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.
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