HESI RN
HESI RN CAT Exit Exam
1. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
- A. Reposition the nasal cannula
- B. Lower the oxygen rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct answer: B
Rationale: In this scenario, the client with COPD receiving increased oxygen is experiencing oxygen toxicity, leading to lethargy and confusion. Lowering the oxygen rate is the priority action to prevent further harm. Repositioning the nasal cannula, encouraging coughing and deep breathing, and monitoring oxygen saturation are all important interventions, but the immediate concern is to address the oxygen toxicity by lowering the oxygen rate.
2. When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
- A. When did your symptoms first begin?
- B. Can you describe the pain and how it feels?
- C. Do you have any changes in vision?
- D. Have you experienced any seizures?
Correct answer: D
Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.
3. A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?
- A. 1000 ml
- B. 800 ml
- C. 760 ml
- D. 500 ml
Correct answer: C
Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.
4. The client with DM is being taught about foot care. The nurse instructs the client to:
- A. Avoid hot water when bathing the feet.
- B. Apply a moisturizing lotion to the feet, especially between the toes.
- C. Use a heating pad to warm the feet if they feel cold.
- D. Go barefoot at home to allow the feet to air out.
Correct answer: A
Rationale: The correct answer is to avoid hot water when bathing the feet. This instruction is crucial because clients with diabetes may have decreased sensation in their feet, which can put them at risk of burns from hot water. Choice B is incorrect because applying moisturizing lotion between the toes can increase moisture and promote fungal growth. Choice C is incorrect because using a heating pad can also lead to burns due to decreased sensation. Choice D is incorrect as going barefoot can increase the risk of injury and infections in clients with diabetes.
5. A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?
- A. Crackles in the lungs
- B. Shortness of breath
- C. Elevated liver enzymes
- D. Heart rate of 100 beats per minute
Correct answer: C
Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.