HESI RN
HESI RN CAT Exit Exam
1. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
- A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
- B. Take vitamin K 10mg PO daily to enhance production of red blood cells
- C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
- D. Combine several legumes and grains such as beans and rice to form complete proteins
Correct answer: D
Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.
2. A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client?
- A. Impaired communication related to paralysis of skeletal muscles.
- B. High risk for infection related to increased intracranial pressure.
- C. Potential for injury related to impaired lung expansion.
- D. Social isolation related to inability to communicate.
Correct answer: A
Rationale: The priority nursing diagnosis for a client on a mechanical ventilator receiving vecuronium bromide is 'Impaired communication related to paralysis of skeletal muscles.' Vecuronium is a skeletal muscle relaxant that causes diaphragmatic paralysis, leading to the inability of the client to communicate effectively. This is a crucial nursing concern as it impacts the client's ability to express needs and participate in care. Option B 'High risk for infection related to increased intracranial pressure' is not the priority in this scenario as the client's condition is related to the effects of the medication and mechanical ventilation, not directly to increased intracranial pressure. Option C 'Potential for injury related to impaired lung expansion' is important but not the priority over impaired communication. Option D 'Social isolation related to inability to communicate' is not the priority nursing diagnosis in this situation as it focuses more on psychosocial aspects rather than the immediate physiological concern of communication impairment.
3. The nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which statement by the client indicates a need for further teaching?
- A. I will use my albuterol inhaler before exercising.
- B. I will avoid secondhand smoke.
- C. I will get a flu shot every year.
- D. I will limit my fluid intake to 2 liters per day.
Correct answer: A
Rationale: Using an albuterol inhaler before exercising is appropriate for clients with COPD to prevent exercise-induced bronchospasm.
4. A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?
- A. Remove the child who has HIV from the foster home.
- B. Report the exposure of the child with HIV to the health department.
- C. Place the child who has HIV in reverse isolation.
- D. Review the immunization documentation of the child who has HIV.
Correct answer: D
Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV to ensure they have received the necessary vaccines. This step is crucial in protecting the child's health and preventing further complications from vaccine-preventable diseases like pertussis. By reviewing the immunization documentation first, the nurse can determine the child's protection against pertussis and other infectious diseases. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately vaccinated. Reporting the exposure to the health department (Choice B) and placing the child in reverse isolation (Choice C) are important steps but reviewing the immunization status takes precedence to assess the child's protection and guide further actions.
5. A male client with impaired renal function who takes ibuprofen daily for chronic arthritis is showing signs of gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70 mm Hg, and his renal output is 20 ml/hour. Which intervention should the nurse include in his care plan?
- A. Maintain the client NPO during the diuresis phase.
- B. Evaluate daily serial renal laboratory studies for progressive elevations.
- C. Observe the urine character for sedimentation and cloudy appearance.
- D. Monitor for the onset of polyuria greater than 150 ml/hour.
Correct answer: B
Rationale: In this scenario, the correct intervention for the nurse to include in the care plan is to evaluate daily serial renal laboratory studies for progressive elevations. This is crucial in monitoring renal function and detecting any worsening renal impairment. Option A is not directly related to managing renal function in this case. Option C focuses more on urinary characteristics rather than renal function monitoring. Option D addresses polyuria, which is an excessive urine output, but it does not specifically address the need for evaluating renal laboratory studies for progressive elevations.