HESI RN
HESI RN CAT Exit Exam
1. 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.
2. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?
- A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
- B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
- C. I know you're upset. Would you like to talk about some activities you could do while in bed?
- D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.
Correct answer: A
Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.
3. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Vastus lateralis muscle
- D. Dorsogluteal muscle
Correct answer: B
Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.
4. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?
- A. An older client who fell yesterday and is now complaining of diplopia.
- B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
- C. A client with pancreatic cancer who is experiencing intractable pain.
- D. An older client post-stroke who is aphasic with right-sided hemiplegia.
Correct answer: D
Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.
5. How can the concept of Integrated Reproductive Health be strengthened?
- A. Through advocacy and IEC
- B. Through community participation
- C. Through radio messages
- D. Through family planning
Correct answer: A
Rationale: The correct answer is A: Through advocacy and IEC. Advocacy and Information, Education, Communication (IEC) campaigns are crucial in strengthening the concept of Integrated Reproductive Health. These efforts help raise awareness, educate the community, and promote positive health behaviors. Choice B, community participation, though important, is not as direct in strengthening the concept as advocacy and IEC. Choice C, radio messages, can be a part of IEC campaigns but alone may not be as effective in strengthening the concept. Choice D, family planning, is a component of Integrated Reproductive Health but is not the most comprehensive approach to strengthening the concept.