HESI V3 PN EXIT EXAM 110 QUESTIONS AND ANSWERS

HESI PN EXIT EXAM V3 110 QUESTIONS cn cn cn cn cn cn




AND ANSWER(S) cn




1. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted
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to the emergency department (ED) with full thickness burns to all surfaces of both lower
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extremities. What percentage of body surface area should the nurse document in the elect
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ronic medical record (EMR)?
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• 9% cn



• 18 % cn




• 36 % cn




• 45 % cn



• Rational: according to the rule of nines, the anterior and posterior surfaces of o
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ne lower extremity is designated as 18 %of total body surface area (TBSA), so
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both extremities equals 36% TBSA, other options are incorrect.
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2. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates tha
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t the medication is having the desired effect?
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• Decrease in serum T4 levels cn cn cn cn



• Increase in blood pressure cn cn cn




• Decrease in pulse rate cn cn cn




• Goiter no longer palpable cn cn cn




3. An older male client with type 2 diabetes mellitus reports that has experiences legs pai
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n when walking short distances, and that the pain is relieved by rest. Which client be
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havior indicates an understanding of healthcare teaching to promote more effective ar
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terial circulation?
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• Consistently applies TED hose before getting dressed in the morning.
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• Frequently elevated legs thorough the day. cn cn cn cn cn



• Inspect the leg frequently for any irritation or skin breakdown
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• Completely stop cigarette/ cigar smoking. cn cn cn cn




• Rationale: Stopping cigarette smoking helps to decrease vasoconstriction an
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d improve arterial circulation to the extremity.
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,4. A community health nurse is concerned about the spread of communicable diseases amon
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g migrant farm workers in a rural community. What action should the nurse take to pro
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mote the success of a healthcare program designed to address this problem?
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• Establish trust with community leaders and respect cultural an
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d family values
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5. The nurse performs a prescribed neurological check at the beginning of the shift on a clie
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nt who was admitted to the hospital with a subarachnoid brain attack (stroke). The client
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’s Glasgow Coma Scale (GCS) score is 9. What information is most important for the n
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urse to determine?
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• The client’s previous GCS score
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• When the client’s stroke symptoms started
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• If the client is oriented to time
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• The client’s blood pressure and respiration rate
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• Rationale: The normal GCS is 15, and it is most important for the nurse
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to determine if it abnormal score a sign of improvement or a deteriorati
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on in the client’s condition
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6. The charge nurse in a critical care unit is reviewing clients’ conditions to determine who i
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s stable enough to be transferred. Which client status report indicates readiness for trans
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fer from the critical care unit to a medical unit?
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• Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
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7. Based on principles of asepsis, the nurse should consider which circumstance to be sterile?
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• One inch- border around the edge of the sterile field set up in the operating room
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• A wrapped unopened, sterile 4x4 gauze placed on a damp table top.
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• An open sterile Foley catheter kit set up on a table at the nurse waist level
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• Sterile syringe is placed on sterile area as the nurse riches over the sterile field.
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• Rationale: A sterile package at or above the waist level is considered sterile. Th
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e edge of sterile field is contaminated which include a 1-
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inch border (A). A sterile objects become contaminated by capillary action whe
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n sterile objects become in contact with a wet contaminated surface.
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8. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spas
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ms when taking the blood pressure using the same arm. After confirming the presence of s
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pams what action should the nurse take?
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• Ask the UAP to take the blood pressure in the other arm
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, • Tell the UAP to use a different sphygmomanometer.
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• Review the client’s serum calcium level
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• Administer PRN antianxiety medication. cn cn cn



• Rationale: Trousseau’s sign is indicated by spasms in the distal portion
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of an extremity that is being used to measure blood pressure and is cause
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d by hypocalcemia (normal level 9.0-
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10.5 mg/dl, so C should be implemented.
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9. A 56-years-
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old man shares with the nurse that he is having difficulty making decision about terminati
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ng life support for his wife. What is the best initial action by the nurse?
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• Provide an opportunity for him to clarify his values related to the decision
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• Encourage him to share memories about his life with his wife and family
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• Advise him to seek several opinions before making decision
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• Offer to contact the hospital chaplain or social worker to offer support.
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• Rationale: When a client is faced with a decisional conflict, the nurse should fir
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st provide opportunities for the client to clarify values important in the decisio
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n. The rest may also be beneficial once the client as clarified the values that ar
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e important to him in the decision-making process.
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10. A client is being discharged home after being treated for heart failure (HF). What instructio
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n should the nurse include in this client’s discharge teaching plan?
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• Weigh every morning cn cn




• Eat a high protein diet
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• Perform range of motion exercises cn cn cn cn



• Limit fluid intake to 1,500 ml daily
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11. A woman just learned that she was infected with Heliobacter pylori. Based on this findin
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g, which health promotion practice should the nurse suggest?
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• Encourage screening for a peptic ulcer cn cn cn cn cn




12. A client who recently underwear a tracheostomy is being prepared for discharge to hom
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e. Which instructions is most important for the nurse to include in the discharge plan?
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• Teach tracheal suctioning techniques
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13. A child with heart failure is receiving the diuretic furosemide (Lasix) and has seru
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m potassium level 3.0 mEq/L. Which assessment is most important for the nurse
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to obtain?
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• Cardiac rhythm and heart rate. cn cn cn cn




• Daily intake of foods rich in potassium.
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