HESI RN
HESI RN CAT Exit Exam
1. A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?
- A. Take the medication with meals
- B. Avoid alcohol while taking this medication
- C. Limit sodium intake
- D. Take the medication at bedtime
Correct answer: B
Rationale: The correct instruction is to advise the client to avoid alcohol while taking phenytoin. Alcohol can interact with phenytoin, making it less effective and leading to increased side effects. Taking the medication with meals (Choice A) may help reduce gastrointestinal upset but is not the most crucial instruction for this medication. Limiting sodium intake (Choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (Choice D) is not a standard instruction for phenytoin administration.
2. A 15-month-old child is brought to the clinic for a routine checkup. The nurse notes that the child is not walking independently yet. What should the nurse do next?
- A. Refer the child for a developmental assessment
- B. Encourage the parents to start physical therapy
- C. Reassure the parents that some children walk later than others
- D. Discuss the importance of early intervention services
Correct answer: C
Rationale: The correct answer is to reassure the parents that some children walk later than others. It is essential to understand that children reach developmental milestones at different ages. Walking independently can occur later in some children, and it is normal. Referring the child for a developmental assessment (Choice A) may cause unnecessary concern at this stage. Encouraging physical therapy (Choice B) or discussing early intervention services (Choice D) may not be warranted unless there are specific concerns identified during the checkup.
3. What is the recommended analgesia for preparing a school-age child for a lumbar puncture (LP)?
- A. Ondansetron (Zofran) 4 mg / 5 ml PO TID.
- B. Codeine 10 mg PO 30 minutes before the procedure.
- C. A transdermal fentanyl (Duragesic) patch immediately before the procedure.
- D. EMLA (eutectic mixtures of local anesthetics) 2.5 hours before the procedure.
Correct answer: D
Rationale: For a lumbar puncture in a school-age child, EMLA cream should be applied 2.5 hours before the procedure. EMLA is commonly used to numb the skin, reducing pain and discomfort for the child during the procedure. Choices A, B, and C are incorrect because ondansetron is an antiemetic, codeine is an opioid analgesic that may not be suitable for children, and transdermal fentanyl is a strong opioid that is not typically used for local anesthesia in children undergoing lumbar puncture.
4. Which of the following is most important for assessing when evaluating the effects of peritoneal dialysis?
- A. Serum potassium levels
- B. Blood pressure
- C. Daily weight
- D. Serum sodium levels
Correct answer: C
Rationale: Daily weight is the most crucial parameter to assess when evaluating the effects of peritoneal dialysis because it directly reflects fluid balance. Peritoneal dialysis involves the removal of excess fluid and waste products from the body. Monitoring daily weight enables the healthcare provider to track changes in fluid status, ensuring that the dialysis treatment is effective. While serum potassium levels, blood pressure, and serum sodium levels are important parameters to monitor in patients undergoing dialysis, they are not as directly indicative of the immediate effects of peritoneal dialysis on fluid balance as daily weight.
5. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
- A. Sensory perceptual alterations related to decreased vision
- B. Alteration in mobility related to fatigue
- C. Impaired gas exchange related to retained secretions
- D. Altered patterns of urinary elimination related to nocturia
Correct answer: D
Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.