HESI RN CAT Exit Exam 1

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HESI RN CAT Exit Exam 1 Questions

Question 1 of 5

A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

Correct Answer: A

Rationale: In this scenario, the client's symptoms of severe pain, numbness, pale skin, and edema below the IO site raise concerns for complications like compartment syndrome or extravasation. The priority action for the nurse is to discontinue the IO infusion to prevent further harm to the client. Administering an analgesic via the IO site or elevating the extremity with the IO site may delay addressing the potential serious complications. While notifying the healthcare provider is important, the immediate action to ensure client safety is to stop the infusion.

Question 2 of 5

In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

Correct Answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

Question 3 of 5

A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

Correct Answer: A

Rationale: In this scenario, the client's symptoms of severe pain, numbness, pale skin, and edema below the IO site raise concerns for complications like compartment syndrome or extravasation. The priority action for the nurse is to discontinue the IO infusion to prevent further harm to the client. Administering an analgesic via the IO site or elevating the extremity with the IO site may delay addressing the potential serious complications. While notifying the healthcare provider is important, the immediate action to ensure client safety is to stop the infusion.

Question 4 of 5

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?

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.

Question 5 of 5

The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?

Correct Answer: A

Rationale: Corrected Rationale: Assessing the client's oxygen saturation level is crucial when a nurse identifies a barrel chest. A barrel chest is often associated with chronic obstructive pulmonary disease (COPD), which can lead to impaired gas exchange and decreased oxygen saturation. Monitoring the oxygen saturation level will provide immediate information on the client's respiratory status. Teaching pursed-lip breathing techniques, determining lung disease history, and obtaining arterial blood gas samples are important interventions but assessing oxygen saturation takes precedence in this scenario due to its direct impact on the client's respiratory function.

Similar Questions

The nurse is performing a physical assessment of a client with a history of smoking and notes a barrel chest. Which action is most important for the nurse to take next?
When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr?
Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client's right leg?
A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?
A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

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