HESI RN CAT Practice: Computer Adaptive
Exam Prep & Review Questions and
Answers
Question 1
The nurse is admitting a client to the unit after fetal death was confirmed by
ultrasound. While initiating intravenous (IV) therapy the nurse notes blood continually
oozing from the puncture site. What is the nurse's next action?
1
Restarting the line distal to the initial site
2
Informing the primary healthcare provider of this finding
3
Starting the prescribed infusion of oxytocin
4
Placing an oxygen mask on the client and setting the flow rate at 8 L/min
Correct Answer
2
Oozing from a venipuncture site is a sign that disseminated intravascular
coagulopathy (DIC) is developing. This pathologic form of clotting causes
widespread bleeding and clotting. It is never a primary diagnosis; it always results
from some problem that has triggered the clotting cascade. The primary healthcare
provider must be informed immediately, because this diagnosis will change the
client's plan of care. There is no information indicating the need for a different IV
site. Also, subsequent venipunctures must be proximal and not distal to previous
sites. Delivery will likely be managed initially with oxytocin; however, this is not the
first action to be taken in regard to an oozing IV site. Generally oxygen is started for
signs of hypoxia, fetal or maternal; because there is no fetal indication for oxygen
and no information in the stem indicating maternal hypoxia, application of oxygen
is not the next intervention.
Page 1 of 545
,Question 2
A client's membranes ruptured 20 hours before admission. The client was in labor for
24 hours before giving birth. For which postpartum complication is this client at risk?
1
Infection
2
Hemorrhage
3
Uterine atony
4
Amniotic fluid embolism
Correct Answer
1
When the membranes rupture, microorganisms from the vagina may travel into the
embryonic sac, causing chorioamnionitis. The longer the time between the rupture
of the membranes and the birth, the greater the risk for infection. The temperature
should be assessed every 1 to 2 hours, and any increase to 100.4° F (38° C) should
be reported. If there are no other complications, hemorrhage and uterine atony are
not expected. Amniotic fluid embolism is not likely to occur when the membranes
rupture before birth, because the fluid exits by way of the vagina rather than being
forced upward.
Page 2 of 545
,Question 3
A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small,
shiny top that she is spinning. Later the father relates his concerns, stating, "She
pushes me away. She doesn't speak, and she only shows feelings when I take her top
away. Is it something I've done?" What is the most therapeutic initial response by the
nurse?
1
Asking the father about his relationship with his wife
2
Asking the father how he held the child when she was an infant
3
Telling the father that it is nothing he has done and sharing the nurse's observations
of the child
4
Telling the father not to be concerned and stressing that the child will outgrow this
developmental phase
Correct Answer
3
The nurse provides support in a nonjudgmental way by sharing information and
observations about the child. This child exhibits symptoms of autism, which is not
attributable to the actions of the parents. Asking the father about his relationship
with his wife or how he held the child when she was an infant indirectly indicates
that the parent may be at fault; it negates the father's need for support and
increases his sense of guilt. Telling the father not to be concerned and stressing that
the child will outgrow this developmental phase is false reassurance that does not
provide support; the father recognizes that something is wrong.
Page 3 of 545
, Question 4
A school-aged child is admitted to the pediatric unit with hypertensive acute
glomerulonephritis. In addition to hydralazine, what medication does the nurse
anticipate will be prescribed initially?
1
Digoxin
2
Furosemide
3
Alprazolam
4
Phenytoin
Correct Answer
2
Furosemide is a loop diuretic that is recommended for the treatment of acute
glomerulonephritis; it promotes the excretion of fluid and thus limits fluid retention.
Digoxin is not used because there is no cardiac involvement. An anxiolytic is
unnecessary. Phenytoin may be used only if hypertensive encephalopathy causes
seizures.
Question 5
After assessing a 5-year-old child, the nurse suspects the child has mumps. Which
symptoms present in the child may support the nurse's suspicion? Select all that
apply.
1
Skin rash
2
Sore throat
3
Fever (100° F-104° F [37.8°-40° C])
4
Difficulty swallowing
5
Swelling of the parotid gland
Correct Answer
35
Mumps is a viral disease that affects the parotid gland. Fever accompanied by
swelling of the parotid gland is a primary symptom of mumps. A skin rash is more
likely to occur with measles. Sore throat and difficulty swallowing are symptoms of
diphtheria.
Page 4 of 545
Exam Prep & Review Questions and
Answers
Question 1
The nurse is admitting a client to the unit after fetal death was confirmed by
ultrasound. While initiating intravenous (IV) therapy the nurse notes blood continually
oozing from the puncture site. What is the nurse's next action?
1
Restarting the line distal to the initial site
2
Informing the primary healthcare provider of this finding
3
Starting the prescribed infusion of oxytocin
4
Placing an oxygen mask on the client and setting the flow rate at 8 L/min
Correct Answer
2
Oozing from a venipuncture site is a sign that disseminated intravascular
coagulopathy (DIC) is developing. This pathologic form of clotting causes
widespread bleeding and clotting. It is never a primary diagnosis; it always results
from some problem that has triggered the clotting cascade. The primary healthcare
provider must be informed immediately, because this diagnosis will change the
client's plan of care. There is no information indicating the need for a different IV
site. Also, subsequent venipunctures must be proximal and not distal to previous
sites. Delivery will likely be managed initially with oxytocin; however, this is not the
first action to be taken in regard to an oozing IV site. Generally oxygen is started for
signs of hypoxia, fetal or maternal; because there is no fetal indication for oxygen
and no information in the stem indicating maternal hypoxia, application of oxygen
is not the next intervention.
Page 1 of 545
,Question 2
A client's membranes ruptured 20 hours before admission. The client was in labor for
24 hours before giving birth. For which postpartum complication is this client at risk?
1
Infection
2
Hemorrhage
3
Uterine atony
4
Amniotic fluid embolism
Correct Answer
1
When the membranes rupture, microorganisms from the vagina may travel into the
embryonic sac, causing chorioamnionitis. The longer the time between the rupture
of the membranes and the birth, the greater the risk for infection. The temperature
should be assessed every 1 to 2 hours, and any increase to 100.4° F (38° C) should
be reported. If there are no other complications, hemorrhage and uterine atony are
not expected. Amniotic fluid embolism is not likely to occur when the membranes
rupture before birth, because the fluid exits by way of the vagina rather than being
forced upward.
Page 2 of 545
,Question 3
A clinic nurse observes a 2-year-old client sitting alone, rocking and staring at a small,
shiny top that she is spinning. Later the father relates his concerns, stating, "She
pushes me away. She doesn't speak, and she only shows feelings when I take her top
away. Is it something I've done?" What is the most therapeutic initial response by the
nurse?
1
Asking the father about his relationship with his wife
2
Asking the father how he held the child when she was an infant
3
Telling the father that it is nothing he has done and sharing the nurse's observations
of the child
4
Telling the father not to be concerned and stressing that the child will outgrow this
developmental phase
Correct Answer
3
The nurse provides support in a nonjudgmental way by sharing information and
observations about the child. This child exhibits symptoms of autism, which is not
attributable to the actions of the parents. Asking the father about his relationship
with his wife or how he held the child when she was an infant indirectly indicates
that the parent may be at fault; it negates the father's need for support and
increases his sense of guilt. Telling the father not to be concerned and stressing that
the child will outgrow this developmental phase is false reassurance that does not
provide support; the father recognizes that something is wrong.
Page 3 of 545
, Question 4
A school-aged child is admitted to the pediatric unit with hypertensive acute
glomerulonephritis. In addition to hydralazine, what medication does the nurse
anticipate will be prescribed initially?
1
Digoxin
2
Furosemide
3
Alprazolam
4
Phenytoin
Correct Answer
2
Furosemide is a loop diuretic that is recommended for the treatment of acute
glomerulonephritis; it promotes the excretion of fluid and thus limits fluid retention.
Digoxin is not used because there is no cardiac involvement. An anxiolytic is
unnecessary. Phenytoin may be used only if hypertensive encephalopathy causes
seizures.
Question 5
After assessing a 5-year-old child, the nurse suspects the child has mumps. Which
symptoms present in the child may support the nurse's suspicion? Select all that
apply.
1
Skin rash
2
Sore throat
3
Fever (100° F-104° F [37.8°-40° C])
4
Difficulty swallowing
5
Swelling of the parotid gland
Correct Answer
35
Mumps is a viral disease that affects the parotid gland. Fever accompanied by
swelling of the parotid gland is a primary symptom of mumps. A skin rash is more
likely to occur with measles. Sore throat and difficulty swallowing are symptoms of
diphtheria.
Page 4 of 545
