HESI RN
HESI RN CAT Exit Exam
1. A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct answer: A
Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.
2. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
- A. The patient’s radial pulse is 105 beats/minute.
- B. There is sediment and blood in the patient’s urine.
- C. The blood pressure increases from 120/80 to 142/94.
- D. There are crackles audible throughout both lung fields.
Correct answer: D
Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.
3. A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
- A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest
- B. Visual problems are unrelated to the recent immunizations
- C. Increase fluid intake to reduce symptoms of fatigue
- D. Consult the healthcare provider immediately for steroid therapy
Correct answer: A
Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. Choice B is incorrect because visual problems can be associated with the immune response triggered by immunizations in individuals with multiple sclerosis. While increasing fluid intake is generally good advice, in this case, the nurse should focus on explaining the possible connection between the immunizations and the symptoms experienced. Choice D is not the immediate course of action; educating the patient on the potential link between immunizations and symptom exacerbation is more appropriate at this stage.
4. Prophase is the first stage of mitosis. Which of the following best describes chromosomes during this stage?
- A. They are gathered on either side of the separating cell
- B. They are all aligned along the metaphase plate
- C. They are attached to the spindle
- D. They are visibly separate
Correct answer: D
Rationale: The correct answer is D. During prophase, the chromosomes condense and become visible as distinct structures under a microscope. Choice A is incorrect as chromosomes are not gathered on either side of the separating cell during prophase. Choice B is incorrect because chromosomes align along the metaphase plate during the subsequent stage, metaphase. Choice C is incorrect as chromosomes become attached to the spindle fibers during prometaphase, the stage following prophase.
5. When assessing the health of a community, what is the most important information for the nurse to obtain?
- A. life expectancy of community members
- B. mortality rates in the community
- C. description of health problems by community leaders
- D. expressed needs of community members
Correct answer: D
Rationale: The most important information for a nurse to obtain when assessing the health of a community is the expressed needs of community members. This information helps in tailoring health interventions to address specific concerns directly expressed by the community. Options A and B focus on statistical data rather than individual needs. Option C, while valuable, may not always capture the full spectrum of health issues faced by the community as perceived by the residents themselves.