HESI RN CAT Exit Exam

Questions 52

HESI RN

HESI RN Test Bank

HESI RN CAT Exit Exam Questions

Question 1 of 5

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?

Correct Answer: A

Rationale: In a 3-year-old boy presenting with dysphagia, drooling, fever, and stridor, the priority intervention should be to place the child in a mist tent. This intervention helps alleviate respiratory distress, providing immediate relief. Options B, C, and D are not as urgent as ensuring the child's airway is managed effectively. Obtaining a sputum culture, preparing for a tracheostomy, and examining the oropharynx can be done after stabilizing the child's respiratory status.

Question 2 of 5

While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?

Correct Answer: C

Rationale: When a nurse observes periods of apnea in a client experiencing Cheyne-Stokes respirations, measuring the length of the apneic periods is essential. This action helps in determining the severity of Cheyne-Stokes respirations by providing valuable information about the duration of interrupted breathing cycles. Elevating the head of the client's bed (Choice A) may be beneficial in some respiratory conditions but is not the priority in Cheyne-Stokes respirations. Auscultating the client's breath sounds (Choice B) is a general assessment and may not directly address the issue of apnea in Cheyne-Stokes respirations. Suctioning the client's oropharynx (Choice D) is not the initial intervention for managing Cheyne-Stokes respirations unless secretions are obstructing the airway.

Question 3 of 5

A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2�F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?

Correct Answer: C

Rationale: Elevated urine specific gravity is a sign of dehydration in children. In the scenario provided, the child is experiencing increased stool frequency, liquid consistency, fever, and vomiting, indicating fluid loss and potential dehydration. Occult blood in the stool may suggest gastrointestinal bleeding but is not a direct indicator of dehydration. Abdominal distention can be seen in various conditions and is not specific to dehydration. Hyperactive bowel sounds are more commonly associated with increased bowel motility, not necessarily dehydration.

Question 4 of 5

The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?

Correct Answer: D

Rationale: Maintaining skeletal pin sites and assessing for infection are critical in skeletal traction care.

Question 5 of 5

A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?

Correct Answer: B

Rationale: The correct instruction is to advise the client to avoid alcohol while taking phenytoin. Alcohol can interact with phenytoin, making it less effective and leading to increased side effects. Taking the medication with meals (Choice A) may help reduce gastrointestinal upset but is not the most crucial instruction for this medication. Limiting sodium intake (Choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (Choice D) is not a standard instruction for phenytoin administration.

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