HESI RN
HESI RN CAT Exit Exam 1
1. The nurse is performing a physical assessment of a male client who has chronic renal failure. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Client reports difficulty breathing
- B. Client reports shortness of breath when lying flat
- C. Client reports swelling in the feet and ankles
- D. Client reports a metallic taste in the mouth
Correct answer: A
Rationale: In a client with chronic renal failure, difficulty breathing is the most critical finding to report. This symptom may indicate fluid overload or pulmonary edema, which can be life-threatening. Shortness of breath when lying flat (orthopnea) is also concerning but less urgent than difficulty breathing. Swelling in the feet and ankles (edema) is a common finding in renal failure but may not be as immediately critical as difficulty breathing. A metallic taste in the mouth is associated with uremia, a common complication of chronic renal failure, but it is not as urgent as respiratory distress.
2. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?
- A. Obtain a speech therapy consult
- B. Elevate the head of the bed
- C. Check the client's lung sounds
- D. Implement aspiration precautions
Correct answer: B
Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.
3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?
- A. Administer a bronchodilator
- B. Encourage deep breathing and coughing
- C. Assess the client's oxygen saturation level
- D. Obtain an arterial blood gas
Correct answer: C
Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.
4. A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left side paralysis
Correct answer: B
Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.
5. A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?
- A. Explain the program's guidelines
- B. Search all personal belongings
- C. Initiate psychosocial assessment
- D. Review the healthcare provider's prescription
Correct answer: B
Rationale: Searching personal belongings is essential to ensure the safety of the client by preventing access to items that could be used for self-harm. While explaining the program's guidelines (Choice A) and initiating a psychosocial assessment (Choice C) are important aspects of care, the immediate concern in this situation is the safety of the client. Reviewing the healthcare provider's prescription (Choice D) is important for providing appropriate treatment but is not as urgent as ensuring the client's safety.
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