HESI RN
HESI RN CAT Exit Exam
1. A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?
- A. Administer 15 grams of carbohydrate
- B. Administer a glucagon injection
- C. Provide a snack with protein
- D. Encourage the client to rest
Correct answer: A
Rationale: The correct action for a client with type 1 diabetes mellitus experiencing hypoglycemia with a blood glucose level of 60 mg/dl is to administer 15 grams of carbohydrate. This will help raise the blood glucose levels quickly. Administering a glucagon injection (Choice B) is usually reserved for severe hypoglycemia where the client is unconscious or unable to swallow. Providing a snack with protein (Choice C) is not the first-line treatment for hypoglycemia as protein takes longer to raise blood glucose levels. Encouraging the client to rest (Choice D) may be beneficial after administering the carbohydrate, but the priority is to raise the blood glucose levels promptly.
2. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.
3. Working in a stressful work environment, nursing requires effective nurse managers. Which of the following skills is necessary for a nurse manager to be effective?
- A. Clinical knowledge
- B. Managerial skills
- C. Patient care coordination
- D. Human resource training
Correct answer: B
Rationale: Managerial skills are crucial for nurse managers to be effective. They need to possess skills such as problem-solving and decision-making to handle various challenges in the healthcare setting. Clinical knowledge (choice A) is important for direct patient care but may not be the primary focus of a manager's role. Patient care coordination (choice C) is vital, but managerial skills are more directly related to a nurse manager's effectiveness. Human resource training (choice D) is helpful but not as essential as managerial skills in ensuring effective leadership in a nursing environment.
4. A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns.
- B. Impaired environmental interpretation.
- C. Disturbed sensory perception.
- D. Compromised family coping.
Correct answer: C
Rationale: The priority nursing problem for admission to the psychiatric unit is 'Disturbed sensory perception.' This choice is correct because the client's delusional beliefs about having an IQ of 400+, being a genius and an inventor, being married to a movie star, and suspecting his brother of wanting a sexual relationship with her indicate a significant disturbance in sensory perception. The client's perceptions are not based in reality, indicating a need for immediate intervention to address these distorted beliefs. Choices A, B, and D are incorrect: 'Ineffective sexual patterns' is not the priority as the client's delusions go beyond just sexual relationships, 'Impaired environmental interpretation' does not capture the primary issue of distorted perceptions, and 'Compromised family coping' is not the priority concern in this scenario compared to the severe sensory perception disturbances displayed by the client.
5. A client's chest tube insertion site has crepitus (crackling sensation) upon palpation. What is the nurse's next step?
- A. Apply a pressure dressing to the chest tube site.
- B. Administer an oral antihistamine.
- C. Assess the client for allergies to cleaning agents.
- D. Measure the area of swelling and crackling.
Correct answer: D
Rationale: The correct next step for the nurse is to measure the area of crepitus. Crepitus indicates subcutaneous emphysema, which is a serious condition requiring monitoring. Applying a pressure dressing (Choice A) could worsen the condition by trapping air under the skin. Administering an oral antihistamine (Choice B) is not indicated for crepitus. Assessing for allergies to cleaning agents (Choice C) is not the priority when dealing with crepitus and subcutaneous emphysema.