HESI RN CAT Exit Exam 1

HESI RN

1. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?

A. Find supplies to put a dressing on the client's wrists
B. Take the client to a room for supervision by staff
C. Call the healthcare provider to report the client's behavior
D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.

2. The nurse is preparing a client for discharge who has a prescription for enoxaparin (Lovenox) self-administration. What information is most important for the nurse to provide the client about this medication?

A. Self-administration techniques for subcutaneous injection
B. Avoiding foods high in vitamin K
C. Signs of bleeding to report to the healthcare provider
D. Proper disposal of used syringes

Correct answer: A

Rationale: Teaching the client about self-administration techniques for subcutaneous injection is crucial for safe and effective use of enoxaparin. Option A is the correct answer as it directly addresses the client's need to know how to properly administer the medication. Options B, C, and D are important aspects of care but are not the most critical information needed for the client's self-administration of enoxaparin.

3. A nurse is assessing the learning needs of a client who is diagnosed with Addison's disease. Which statement indicates that the client needs further teaching?

A. I should take my medications daily to replace necessary hormones
B. I need to eat a diet high in protein and carbohydrates
C. I should avoid drinking fluids with caffeine
D. I should notify my healthcare provider if I start feeling dizzy

Correct answer: B

Rationale: The correct answer is B. A diet high in protein and carbohydrates is not specifically required for Addison's disease. The focus should be on maintaining a balanced diet that is rich in fruits, vegetables, whole grains, and adequate protein sources. Choice A is correct as adherence to medication therapy is crucial in managing Addison's disease. Choice C is correct as caffeine can exacerbate symptoms of Addison's disease. Choice D is correct as dizziness can be a sign of adrenal crisis in Addison's disease, and prompt notification of healthcare providers is essential.

4. 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 clientâ€™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.

5. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 32 breaths/min and a heart rate of 110 beats/min. What action should the nurse take first?

A. Administer a bronchodilator
B. Encourage deep breathing and coughing
C. Assess the client's oxygen saturation level
D. Obtain an arterial blood gas

Correct answer: C

Rationale: The correct action for the nurse to take first is to assess the client's oxygen saturation level. In a client with COPD and abnormal respiratory and heart rates, determining the oxygen saturation helps evaluate the adequacy of oxygen exchange and the severity of respiratory distress. Administering a bronchodilator (choice A) can be appropriate but assessing oxygen saturation takes priority. Encouraging deep breathing and coughing (choice B) may not address the immediate need for oxygenation assessment. Obtaining an arterial blood gas (choice D) is important but typically follows the initial assessment of oxygen saturation.