HESI RN
HESI RN CAT Exit Exam
1. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
- A. Use manual pressure to express urine
- B. Perform the Crede maneuver
- C. Apply an external urinary drainage device
- D. Take a warm sitz bath twice a day
Correct answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.
2. A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client’s teaching plan?
- A. Avoid all forms of sugar
- B. Check blood glucose levels once a week
- C. Rotate insulin injection sites
- D. Monitor urine ketone levels
Correct answer: C
Rationale: Rotating insulin injection sites prevents lipodystrophy and ensures proper insulin absorption.
3. The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct answer: D
Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.
4. The mother of a 6-year-old anemic boy is taught by the nurse to give iron supplements. Which statement indicates that the mother understands the proper administration of iron?
- A. The iron tablets will be absorbed between meals, on an empty stomach
- B. I should give the iron tablets with his milk and cereal each morning
- C. Iron preparations can be taken with antibiotics if he develops an infection
- D. The iron tablets may cause him to sunburn more easily so he should wear sunscreen
Correct answer: A
Rationale: The correct answer is A because iron supplements are best absorbed on an empty stomach, which maximizes their effectiveness. Giving iron tablets with milk or calcium-rich foods, as mentioned in choice B, should be avoided as they can decrease iron absorption. Choice C is incorrect because iron preparations should not be taken with antibiotics due to potential interactions. Choice D is also incorrect as iron tablets do not cause an increased risk of sunburn, so sunscreen is not necessary specifically due to iron supplementation.
5. A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
- A. Refer the client to a healthcare provider for a pelvic examination
- B. Notify the parents that the client needs to be picked up from school
- C. Determine the date of the client's last menstrual period
- D. Ask the client to lie down for a pelvic examination
Correct answer: A
Rationale: The correct action the nurse should take first is to refer the client to a healthcare provider for a pelvic examination. This is important to rule out serious conditions that may be causing the abdominal pain and dysmenorrhea. While notifying the parents, determining the date of the client's last menstrual period, and asking the client to lie down for a pelvic examination could be necessary steps, the priority is to ensure a proper evaluation by a healthcare provider to address the client's presenting symptoms effectively.
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