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. While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct answer: C
Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.
3. The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct answer: C
Rationale: The correct answer is C, International Normalized Ratio (INR). While INR is commonly used to monitor the effectiveness of warfarin therapy, in the case of heparin therapy, the Partial Thromboplastin Time (PTT) is the preferred test. Choice A, Prothrombin Time (PT), measures the activity of the extrinsic pathway of coagulation and is not the best choice for monitoring heparin therapy. Choice D, Activated Partial Thromboplastin Time (aPTT), is similar to PTT and is used to monitor heparin therapy, but PTT is the more specific test. Therefore, monitoring PTT is crucial in determining the effectiveness and safety of heparin therapy.
4. An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?
- A. The emergency department is very busy at this time.
- B. I'll let you see the doctor next because you've waited so long.
- C. I'm doing the best I can for the sickest clients first.
- D. I understand you are frustrated with the wait time.
Correct answer: D
Rationale: The correct response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response acknowledges the client's emotions, shows empathy, and validates their feelings of frustration. Option A justifies the situation but does not address the client's emotional state. Option B is unfair to other patients and may not be based on urgency. Option C focuses on the nurse's actions rather than addressing the client's emotions, making it less effective than option D.
5. A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action?
- A. Administer an IV of normal saline rapidly and NPH insulin subcutaneously.
- B. Administer a retention enema of Kayexalate.
- C. Add 40 mEq of KCL (potassium chloride) to the present IV solution.
- D. Administer a lidocaine bolus IV push.
Correct answer: B
Rationale: In acute renal failure with a high serum potassium level, the priority intervention is to lower potassium levels to prevent complications like cardiac arrhythmias. Administering a retention enema of Kayexalate is the correct action as it helps lower high potassium levels by exchanging sodium for potassium in the intestines. Options A, C, and D are incorrect. Administering normal saline rapidly and NPH insulin or adding more potassium to the IV solution can further increase potassium levels, worsening the condition. Lidocaine is not indicated for treating hyperkalemia.
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