HESI RN
HESI RN CAT Exit Exam
1. A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?
- A. Impaired physical mobility
- B. Ineffective breathing pattern
- C. Impaired skin integrity
- D. Risk for infection
Correct answer: B
Rationale: Ineffective breathing pattern is the highest priority for a client in the late stage of ALS due to the significant risk of respiratory complications. As ALS progresses, the client may experience respiratory muscle weakness, leading to ineffective breathing patterns and potential respiratory failure. Addressing breathing difficulties promptly is crucial to ensure adequate oxygenation and prevent further complications. While impaired physical mobility, impaired skin integrity, and risk for infection are also important concerns in ALS care, they are secondary to addressing the client's breathing difficulties, which take precedence to maintain physiological stability and prevent life-threatening consequences.
2. Discuss the anatomical/physiological changes in pregnancy under the following: Cardiovascular system
- A. The heart is displaced upward and to the left by the enlarging uterus, cardiac capacity increases, and blood pressure declines slightly.
- B. The heart is displaced downward and to the right, and blood pressure increases.
- C. The cardiovascular system remains unchanged during pregnancy.
- D. Cardiovascular changes include increased peripheral resistance and reduced cardiac output.
Correct answer: A
Rationale: During pregnancy, the cardiovascular system undergoes changes such as the heart being displaced upward and to the left by the enlarging uterus, increased cardiac capacity, and a slight decline in blood pressure. Choice B is incorrect as the heart is displaced upwards, not downwards, and blood pressure typically decreases slightly. Choice C is incorrect as the cardiovascular system does undergo changes during pregnancy. Choice D is incorrect as cardiovascular changes in pregnancy involve increased cardiac output rather than reduced output.
3. The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client’s safety?
- A. Encourage the client to use oxygen continuously
- B. Monitor the client’s respiratory rate and effort
- C. Set the oxygen flow rate at 6 liters per minute
- D. Teach the client to avoid wearing wool blankets
Correct answer: B
Rationale: Monitoring the client’s respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.
4. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?
- A. Increase intake of potassium-rich foods.
- B. Report increased bruising or bleeding.
- C. Stop medication if a cough develops.
- D. Limit intake of leafy green vegetables.
Correct answer: B
Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.
5. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Inspect the PICC insertion site for signs of infection.
- B. Observe the antecubital fossa for inflammation.
- C. Auscultate lung sounds for signs of respiratory distress.
- D. Check for signs of phlebitis or thrombosis along the catheter site.
Correct answer: B
Rationale: Observing the antecubital fossa for inflammation is crucial in clients with a PICC line and fever. Inflammation at the site can indicate infection or complications related to the PICC line. Auscultating lung sounds (choice C) is important but not the priority in this situation. Checking for phlebitis or thrombosis (choice D) is relevant but does not address the immediate concern of identifying infection or complications at the insertion site. Inspecting the PICC insertion site (choice A) is also important but observing the antecubital fossa provides a more direct assessment of potential issues with the PICC line.