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6-
2027 ALL 110 QUESTIONS AND VERIFIED ANS
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WERS PLUS RATIONALES/PN HESI EXIT EXA
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M V3 h
1. Anhadulthclienthexperienceshahgasolinehtankhfirehwhenhridinghahmotorcyclehandhishadmittedhtoht
hehemergencyhdepartmenth(ED)hwithhfullhthicknesshburnshtohallhsurfaceshofhbothhlowerhextrem
ities.hWhathpercentagehofhbodyhsurfacehareahshouldhthehnursehdocumenthinhthehelectronichmed
icalhrecordh(EMR)?
• 9h%
• 18h%
• 36h%
• 45h%
• Rational:haccordinghtohthehrulehofhnines,hthehanteriorhandhposteriorhsurfaceshofhonehl
owerhextremityhishdesignatedhash18h%ofhtotalhbodyhsurfacehareah(TBSA),hsohbothhe
xtremitieshequalsh36%hTBSA,hotherhoptionsharehincorrect.
2. Ahclienthwithhhyperthyroidismhishreceivinghpropranololh(Inderal).hWhichhfindinghindicateshthatht
hehmedicationhishhavinghthehdesiredheffect?
• DecreasehinhserumhT4hlevels
• Increasehinhbloodhpressure
• Decreasehinhpulsehrate
• Goiterhnohlongerhpalpable
3. Anholderhmalehclienthwithhtypeh2hdiabeteshmellitushreportshthathhashexperienceshlegshpainhw
henhwalkinghshorthdistances,handhthaththehpainhishrelievedhbyhrest.hWhichhclienthbehaviorhin
dicateshanhunderstandinghofhhealthcarehteachinghtohpromotehmoreheffectiveharterialhcirculat
ion?
• ConsistentlyhapplieshTEDhhosehbeforehgettinghdressedhinhthehmorning.
• Frequentlyhelevatedhlegshthoroughhthehday.
• Inspecththehleghfrequentlyhforhanyhirritationhorhskinhbreakdown
• Completelyhstophcigarette/hcigarhsmoking.
• Rationale:hStoppinghcigarettehsmokinghhelpshtohdecreasehvasoconstrictionhandhi
mproveharterialhcirculationhtohthehextremity.
4. Ahcommunityhhealthhnursehishconcernedhabouththehspreadhofhcommunicablehdiseaseshamonghmi
granthfarmhworkershinhahruralhcommunity.hWhathactionhshouldhthehnursehtakehtohpromotehthehsuc
cesshofhahhealthcarehprogramhdesignedhtohaddresshthishproblem?
• Establishhtrusthwithhcommunityhleadershandhrespecthculturalhandhfamilyh
values
,5. Thehnursehperformshahprescribedhneurologicalhcheckhaththehbeginninghofhthehshifthonhahclienth
whohwashadmittedhtohthehhospitalhwithhahsubarachnoidhbrainhattackh(stroke).hThehclient’shGlas
gowhComahScaleh(GCS)hscorehish9.hWhathinformationhishmosthimportanthforhthehnursehtohdeter
mine?
• Thehclient’shprevioushGCShscore
• Whenhthehclient’shstrokehsymptomshstarted
• Ifhthehclienthishorientedhtohtime
• Thehclient’shbloodhpressurehandhrespirationhrate
• Rationale:hThehnormalhGCShish15,handhithishmosthimportanthforhthehnursehtohdet
erminehifhithabnormalhscorehahsignhofhimprovementhorhahdeteriorationhinhthehclie
nt’shcondition
6. Thehchargehnursehinhahcriticalhcarehunithishreviewinghclients’hconditionshtohdeterminehwhohishs
tablehenoughhtohbehtransferred.hWhichhclienthstatushreporthindicateshreadinesshforhtransferhfr
omhthehcriticalhcarehunithtohahmedicalhunit?
• Chronichliverhfailurehwithhahhemoglobinhofh10.1handhslighthbilirubinhelevation
7. Basedhonhprincipleshofhasepsis,hthehnursehshouldhconsiderhwhichhcircumstancehtohbehsterile?
• Onehinch-hborderharoundhthehedgehofhthehsterilehfieldhsethuphinhthehoperatinghroom
• Ahwrappedhunopened,hsterileh4x4hgauzehplacedhonhahdamphtablehtop.
• AnhopenhsterilehFoleyhcatheterhkithsethuphonhahtablehaththehnursehwaisthlevel
• Sterilehsyringehishplacedhonhsterilehareahashthehnursehricheshoverhthehsterilehfield.
• Rationale:hAhsterilehpackagehathorhabovehthehwaisthlevelhishconsideredhsterile.hThehe
dgehofhsterilehfieldhishcontaminatedhwhichhincludehah1-inchhborderh(A).hAhsterile
objectshbecomehcontaminatedhbyhcapillaryhactionhwhenhsterilehobjectshbecomehinhco
ntacthwithhahwethcontaminatedhsurface.
8. Anhunlicensedhassistivehpersonnelh(UAP)hreportshthathahclient’shrighthhandhandhfingershspasmsh
whenhtakinghthehbloodhpressurehusinghthehsameharm.hAfterhconfirminghthehpresencehofhspamsh
whathactionhshouldhthehnursehtake?
• AskhthehUAPhtohtakehthehbloodhpressurehinhthehotherharm
• TellhthehUAPhtohusehahdifferenthsphygmomanometer.
• Reviewhthehclient’shserumhcalciumhlevel
• AdministerhPRNhantianxietyhmedication.
• Rationale:hTrousseau’shsignhishindicatedhbyhspasmshinhthehdistalhportionhofhanhe
xtremityhthathishbeinghusedhtohmeasurehbloodhpressurehandhishcausedhby
, hypocalcemiah(normalhlevelh9.0-10.5hmg/dl,hsohChshouldhbehimplemented.
9. Ah56-years-
oldhmanhshareshwithhthehnursehthathhehishhavinghdifficultyhmakinghdecisionhabouthterminatinghl
ifehsupporthforhhishwife.hWhathishthehbesthinitialhactionhbyhthehnurse?
• Providehanhopportunityhforhhimhtohclarifyhhishvalueshrelatedhtohthehdecision
• Encouragehhimhtohsharehmemorieshabouthhishlifehwithhhishwifehandhfamily
• Advisehhimhtohseekhseveralhopinionshbeforehmakinghdecision
• Offerhtohcontacththehhospitalhchaplainhorhsocialhworkerhtohofferhsupport.
• Rationale:hWhenhahclienthishfacedhwithhahdecisionalhconflict,hthehnursehshouldhfirsthp
rovidehopportunitieshforhthehclienthtohclarifyhvalueshimportanthinhthehdecision.hThe
resthmayhalsohbehbeneficialhoncehthehclienthashclarifiedhthehvalueshthatharehimportant
htohhimhinhthehdecision-makinghprocess.
10. Ahclienthishbeinghdischargedhhomehafterhbeinghtreatedhforhhearthfailureh(HF).hWhathinstructionhs
houldhthehnursehincludehinhthishclient’shdischargehteachinghplan?
• Weighheveryhmorning
• Eathahhighhproteinhdiet
• Performhrangehofhmotionhexercises
• Limithfluidhintakehtoh1,500hmlhdaily
11. AhwomanhjusthlearnedhthathshehwashinfectedhwithhHeliobacterhpylori.hBasedhonhthishfinding,h
whichhhealthhpromotionhpracticehshouldhthehnursehsuggest?
• Encouragehscreeninghforhahpeptichulcer
12. Ahclienthwhohrecentlyhunderwearhahtracheostomyhishbeinghpreparedhforhdischargehtohhome.h
Whichhinstructionshishmosthimportanthforhthehnursehtohincludehinhthehdischargehplan?
• Teachhtrachealhsuctioninghtechniques
13. Ahchildhwithhhearthfailurehishreceivinghthehdiuretichfurosemideh(Lasix)handhhashserumhpota
ssiumhlevelh3.0hmEq/L.hWhichhassessmenthishmosthimportanthforhthehnursehtohobtain?
• Cardiachrhythmhandhhearthrate.
• Dailyhintakehofhfoodshrichhinhpotassium.
• Hourlyhurinaryhoutput
• Thirsthadhskinhturgor.
14. Thehnursehnotehahdepressedhfemalehclienthhashbeenhmorehwithdrawnhandhnon-
communicativehduringhthehpasthtwohweeks.hWhichhinterventionhishmosthimportanthtohincludehi
nhthehupdatedhplanhofhcarehforhthishclient?