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. The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
- A. Monitor the client's respiratory status
- B. Teach the client how to use the PCA pump
- C. Evaluate the client's pain level
- D. Assess the client's pain level
Correct answer: A
Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.
3. The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?
- A. Provide educational materials on smoking cessation
- B. Offer blood pressure screening and monitoring
- C. Provide information on safe sex practices
- D. Discuss the importance of a healthy diet and exercise
Correct answer: B
Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.
4. The healthcare provider prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled Amoxicillin (Amoxil) suspension 200 mg/5 ml. How many ml should the nurse administer every 8 hours?
- A. 10 ml
- B. 12.5 ml
- C. 15 ml
- D. 17.5 ml
Correct answer: B
Rationale: To calculate the correct dosage, first, determine the total daily dose: 1.5 grams = 1500 mg. Since the medication is 200 mg/5 ml, for 1500 mg, the nurse needs to administer 1500/200 = 7.5 times the 5 ml dose. Therefore, 7.5 x 5 ml = 37.5 ml total daily dose. To administer this every 8 hours, divide 37.5 ml by 3 (8 hours intervals in a day) to get 12.5 ml to be administered every 8 hours. Choice A, C, and D are incorrect as they do not reflect the correct calculation of the dose based on the prescription and the available concentration.
5. 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.
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