HESI RN
HESI RN CAT Exit Exam
1. The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
- A. A 45-year-old with chronic hepatitis B.
- B. A 35-year-old with lupus erythematosus
- C. A 19-year-old diagnosed with rubella
- D. A 25-year-old with herpes lesions of the vulva
Correct answer: B
Rationale: The correct answer is B because a client with lupus erythematosus can be safely transferred to the antepartal unit as this condition does not pose a significant risk to other patients or staff. Choices A, C, and D should not be recommended for transfer to the antepartal unit due to the potential risks they may pose to pregnant women and their unborn babies. Chronic hepatitis B, rubella, and herpes lesions of the vulva can be contagious and harmful in the perinatal setting.
2. A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct answer: A
Rationale: The correct answer is A: 'Blow cool air from a hairdryer under the cast.' Blowing cool air can help relieve itching without damaging the cast or causing injury. Choice B, twisting the cast back and forth, can lead to discomfort, skin irritation, or even injury. Choice C, shaking powder into the cast, can create a mess, increase the risk of skin issues, and interfere with proper healing. Choice D, pushing a pencil under the cast edge, is dangerous as it can cause injury to the child's skin or the underlying tissues. Therefore, the safest and most effective option to relieve itching under the cast is to blow cool air from a hair dryer.
3. A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take?
- A. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
- B. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour
- C. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection
- D. Advise the client to rest and hydrate, then return if contractions become more regular
Correct answer: B
Rationale: The client should be instructed to call when contractions are 5 minutes apart for an hour to ensure she is in active labor before going to the hospital.
4. A 20-year-old male client is diagnosed with Ewing's sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?
- A. Take analgesics regularly to reduce the pain
- B. Notify the healthcare provider if the swelling worsens
- C. Avoid weight-bearing until the injury heals
- D. Seek treatment for the sarcoma immediately
Correct answer: D
Rationale: The correct answer is to instruct the client to seek treatment for the sarcoma immediately. Ewing's sarcoma is an aggressive cancer, and prompt treatment is crucial for improving prognosis. Option A is incorrect because while pain management is important, addressing the underlying cause (sarcoma) is the priority. Option B is not as critical as seeking treatment for the sarcoma itself. Option C is not the most important instruction as the primary concern is addressing the cancer diagnosis.
5. The nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client. Which action is most important for the nurse to take?
- A. Verify the client's blood type
- B. Ensure the PRBCs are warm
- C. Check the client's vital signs
- D. Obtain the client's consent
Correct answer: A
Rationale: Verifying the client's blood type is crucial before administering PRBCs to ensure compatibility and prevent transfusion reactions. Checking the client's blood type is essential in blood transfusions. Ensuring the PRBCs are warm is not a priority as the temperature should be within a specific range regardless of the client's preference. Checking the client's vital signs is important but not as crucial as verifying the blood type before a blood transfusion. Obtaining the client's consent is important for any procedure but does not directly impact the safety and success of administering PRBCs.
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