HESI RN CAT Exit Exam 1

Correct Answer: C

Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice D) involves transferring emotions from one target to another.

Correct Answer: D

Rationale: The correct answer is to monitor serum creatinine levels. Acyclovir can potentially impact kidney function, making it essential to monitor serum creatinine levels to assess renal function. Option A, initiating cardiac telemetry monitoring, is not directly related to acyclovir administration for herpes zoster. Option B, maintaining continuous pulse oximetry, is more relevant in assessing respiratory status rather than monitoring for acyclovir-related side effects. Option C, performing capillary glucose measurements, is not directly associated with acyclovir therapy for herpes zoster.

Correct Answer: C

Rationale: Keeping the radiated area dry and clean is crucial to prevent skin irritation and infection. Radiation therapy can cause skin changes, making it susceptible to irritation and infection. Using sunscreen (Choice A) is not usually recommended on the radiated area as it can further irritate the skin. Applying lotion (Choice B) may not be suitable as it can trap moisture and cause skin breakdown. While encouraging exercise (Choice D) is important, keeping the area dry and clean takes precedence to prevent complications during radiation therapy.

Correct Answer: A

Rationale: The correct answer is A. Using crutches indicates an understanding of weight-bearing restrictions post-surgery. Choice B is incorrect because waiting for a wheelchair is not related to postoperative mobility instructions. Choice C is incorrect as turning in bed using the trapeze bar and side rails does not address weight-bearing restrictions. Choice D is incorrect because putting full weight on the foot immediately after surgery contradicts the need to keep weight off the knee.

Correct Answer: D

Rationale: Successful extubation relies on the patient's ability to maintain an effective breathing pattern. This indicates that the patient can adequately oxygenate and ventilate without the need for mechanical support. Monitoring tissue perfusion, preventing infection, and ensuring safety are important but not directly related to the immediate criteria for successful extubation. Tissue perfusion, injury prevention, and infection control are crucial aspects of overall patient care but are not the primary factors to consider when evaluating readiness for extubation.