HESI RN
HESI RN CAT Exit Exam
1. The nurse is caring for a client who is 2 days post-op following an abdominal hysterectomy. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct answer: A
Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps to cover and protect the exposed bowel, preventing infection and maintaining a moist environment for wound healing. Option B, notifying the healthcare provider, is important but should come after addressing the immediate need of covering the wound. Administering pain medication (option C) and covering the wound with an abdominal binder (option D) are not appropriate initial actions for this situation.
2. A healthcare professional is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The healthcare professional interprets that the tube is positioned above:
- A. The first tracheal cartilaginous ring
- B. The point where the larynx connects to the trachea
- C. The bifurcation of the right and left main stem bronchi
- D. The area connecting the oropharynx to the laryngopharynx
Correct answer: C
Rationale: The carina is a cartilaginous ridge that separates the openings of the two main stem (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main stem bronchus due to the natural curvature of the airway. This positioning is dangerous as only the right lung will be ventilated. It can be identified as only the right lung will have breath sounds and rise and fall with ventilation. Choices A, B, and D are incorrect as they do not relate to the specific anatomical landmark mentioned in the scenario.
3. During which stage of mitosis does the nuclear envelope begin to disappear and the chromosomes start attaching to the spindle forming along the cell's axis?
- A. Prometaphase
- B. Metaphase
- C. Anaphase
- D. Prophase
Correct answer: A
Rationale: The correct answer is A, Prometaphase. During prometaphase, the nuclear envelope disintegrates, and chromosomes start attaching to spindle fibers. In metaphase, chromosomes align in the middle of the cell. Anaphase is characterized by the separation of sister chromatids, and prophase involves the condensation of chromosomes and the beginning of spindle formation.
4. A public health nurse is developing a campaign to promote breast cancer screening. Which population should be the primary target of this campaign?
- A. women aged 20-30
- B. women aged 30-40
- C. women aged 40-50
- D. women aged 50-60
Correct answer: C
Rationale: The correct answer is women aged 40-50. This age group is at an increased risk for breast cancer and should be the primary target for screening campaigns. Women in this age range are more likely to benefit from regular screening as early detection can lead to better outcomes. Choices A, B, and D are incorrect because women aged 20-30 are generally not recommended for routine screening due to their lower risk, women aged 30-40 have a moderate risk but are not the primary target group, and women aged 50-60 should still be screened but targeting the 40-50 age group is more crucial for early detection and intervention.
5. The father of an 11-year-old client reports to the nurse that the client has been wetting the bed since the passing of his mother and is concerned. Which action is most important for the nurse to take?
- A. Reassure the father that it is normal for a pre-teen to wet the bed during times of stress
- B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
- C. Inform the father that it is most important to let the son know that bedwetting is normal after trauma
- D. Refer the father and the client to a psychologist
Correct answer: D
Rationale: It is common for children to experience bedwetting as a response to severe trauma, such as losing a parent. Referring the father and the client to a psychologist is crucial in this situation to help the child cope with the loss and address any underlying emotional issues. Choice A is incorrect as bedwetting in this context is likely related to the trauma rather than puberty. Choice B is incorrect as nocturnal emissions are not abnormal and do not relate to bedwetting. Choice C is incorrect because the focus should be on addressing the emotional impact of the trauma rather than specifically discussing bedwetting.