HESI RN CAT Exit Exam

HESI RN CAT Exit Exam Related

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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: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.

Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.

Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.

Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.

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A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?

  • A. Bladder distention
  • B. Serum albumin level
  • C. Abdominal girth
  • D. Breath sounds
Correct Answer: D

Rationale: The correct answer is D (Breath sounds). Pitting edema is a common side effect of amlodipine due to vasodilation. It can also lead to pulmonary edema, causing shortness of breath and crackles on auscultation. Therefore, assessing breath sounds is crucial to detect any signs of fluid overload and potential pulmonary complications. Bladder distention (A) is not directly related to the client's current symptoms. Serum albumin level (B) may indicate protein status but is not immediately necessary in this case. Abdominal girth (C) is more indicative of ascites or abdominal distension, not directly related to the client's edema and possible pulmonary complications.

A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?

  • A. Place the child in a mist tent
  • B. Obtain a sputum culture
  • C. Prepare for an emergent tracheostomy
  • D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct Answer: A

Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.

What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

  • A. Bladder palpation
  • B. Inspection of the mouth
  • C. Blood glucose monitoring
  • D. Auscultation of breath sounds
Correct Answer: B

Rationale: The correct answer is B: Inspection of the mouth. Phenytoin can cause gingival hyperplasia as a common untoward effect. By inspecting the mouth regularly, the nurse can assess for signs of this side effect such as swollen or bleeding gums. Bladder palpation (A) is not relevant to monitoring phenytoin side effects. Blood glucose monitoring (C) is not typically associated with phenytoin use. Auscultation of breath sounds (D) is not directly related to monitoring for phenytoin side effects.

A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

  • A. Weight gain of 2 pounds in 24 hours
  • B. Presence of a cough
  • C. Edema in the lower extremities
  • D. Shortness of breath
Correct Answer: D

Rationale: The correct answer is D: Shortness of breath. This assessment finding is crucial in a client with CHF and fluid volume overload as it indicates potential worsening of heart failure leading to pulmonary congestion. Shortness of breath is a common symptom of fluid accumulation in the lungs, requiring immediate intervention to prevent respiratory distress.

A: Weight gain of 2 pounds in 24 hours may indicate fluid retention but is not as urgent as shortness of breath.
B: Presence of a cough can be a symptom of CHF but is not as specific or concerning as shortness of breath.
C: Edema in the lower extremities is also a common finding in CHF but does not directly signify acute respiratory compromise as shortness of breath does.

A nurse is planning care for a client in the late stage of amyotrophic lateral sclerosis (ALS). Which nursing diagnosis has the highest priority?

  • A. Impaired physical mobility
  • B. Ineffective breathing pattern
  • C. Impaired skin integrity
  • D. Risk for infection
Correct Answer: B

Rationale: The correct answer is B: Ineffective breathing pattern. In late-stage ALS, respiratory muscles weaken, leading to breathing difficulties. Priority is given to maintaining adequate oxygenation and ventilation. Impaired physical mobility (choice A) is important but not the highest priority. Impaired skin integrity (choice C) and risk for infection (choice D) may result from immobility but are secondary to the critical issue of breathing in this scenario.

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