HESI RN
HESI RN CAT Exit Exam 1
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. Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?
- A. A young adult client with intractable vomiting due to food poisoning
- B. A client who developed hyperparathyroidism in late adolescence
- C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
- D. A female client who excessively consumes simple carbohydrates
Correct answer: C
Rationale: The correct answer is C. Clients in renal failure are at high risk for hypomagnesemia due to their impaired kidney function. Renal failure can lead to decreased excretion of magnesium, resulting in its buildup in the body and potential hypomagnesemia. This client requires careful nursing assessment for signs and symptoms of hypomagnesemia to prevent complications. Choices A, B, and D are not as directly associated with renal failure and its impact on magnesium levels. Intractable vomiting, hyperparathyroidism, and excessive consumption of simple carbohydrates may have other health implications but are not as strongly linked to hypomagnesemia as renal failure.
3. A nurse is planning care for a client who is receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
- A. Administer an antiemetic before meals
- B. Provide frequent mouth care
- C. Encourage small, frequent meals
- D. Offer clear liquids
Correct answer: A
Rationale: Administering an antiemetic before meals is a crucial intervention to manage chemotherapy-induced nausea. Antiemetics are medications specifically designed to prevent or relieve nausea and vomiting. By administering the antiemetic before meals, the nurse can help prevent the onset of nausea, allowing the client to eat more comfortably. Providing frequent mouth care (Choice B) is important for maintaining oral hygiene but does not directly address nausea. Encouraging small, frequent meals (Choice C) and offering clear liquids (Choice D) are generally recommended for clients experiencing nausea, but administering an antiemetic is a more targeted approach to specifically address and manage the symptom.
4. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client?
- A. Maintain a quiet environment
- B. Ensure the linens are clean and dry
- C. Place an air deodorizer in the room
- D. Measure all emesis accurately
Correct answer: D
Rationale: The correct answer is D, 'Measure all emesis accurately.' When a client with a small bowel obstruction is experiencing frequent vomiting, measuring emesis accurately is crucial for monitoring fluid balance and preventing dehydration. Choice A, 'Maintain a quiet environment,' while important for patient comfort, is not as critical as accurately measuring emesis. Choices B and C, 'Ensure the linens are clean and dry' and 'Place an air deodorizer in the room,' focus on environmental factors that, although helpful, are not as essential as monitoring the client's fluid balance in this situation.
5. A client who is gravida 1, para 0, is admitted to the birthing suite in early labor and requests pain relief. Which action should the nurse implement?
- A. Encourage the client to use distraction techniques
- B. Offer to teach the client relaxation techniques
- C. Determine the client’s pain level and location
- D. Administer an opioid analgesic as prescribed
Correct answer: D
Rationale: In this scenario, the correct action for the nurse to implement is to administer an opioid analgesic as prescribed. Since the client is in early labor and requesting pain relief, opioids are commonly used to provide effective pain relief during labor. Encouraging distraction or teaching relaxation techniques may not be sufficient for pain management during labor, especially in the early stages when the pain intensity can increase rapidly. Determining the pain level and location is important but administering the prescribed opioid is the most appropriate action to address the client's request for pain relief.
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