HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWER(S)

HESI PN EXIT EXAM V3 110 QUESTIONS
AND ANSWER(S)

1. Anadult client experiences agasolinetank firewhen riding amotorcycle and is admitted to the em
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ergencydepartment (ED) withfull thickness burnsto allsurfaces ofbothlowerextremities
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.What percentageofbodysurface areashouldthenursedocumentin theelectronicmedical re cord
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(EMR)?
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• 9% w
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• 18% w
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• 45% w
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• Rational: accordingto therule ofnines, the anterior and posterior surfaces of one lo w
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erextremityis designatedas18%oftotalbodysurfacearea(TBSA), so bothextre mitie
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s equals 36% TBSA, other options are incorrect.
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2. Aclient with hyperthyroidismisreceivingpropranolol(Inderal).Whichfindingindicatesthat the
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medication is having the desired effect?sw sw sw sw sw




• Decreasein serumT4 levels sw sw sw sw




• Increasein blood pressure sw sw sw




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• Goiternolonger palpable sw sw sw




3. An older male client withtype 2 diabetesmellitus reports thathas experiences legs pain wh en
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walking short distances, and that the pain is relieved by rest. Which client behavior indi cates
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an understanding of healthcare teaching to promote more effective arterial circulatio n?
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• Consistently applies TED hosebefore getting dressedin themorning. vc sw sw sw sw




• Frequently elevatedlegs thorough the day. sw sw sw sw sw




• Inspectthe legfrequently for any irritation or skin breakdownsw sw sw vc sw sw




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• Rationale: Stopping cigarettesmoking helps to decrease vasoconstriction and i m
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prove arterial circulation to the extremity.
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the su
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• Establish trust with communityleadersandrespectculturaland fa vc vc vc sw sw sw




mily values w
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5. Thenurseperforms a prescribed neurological check at the beginning of the shift on a client wh o sw sw vc sw vc sw vc sw sw vc sw sw sw sw sw




was admitted to the hospitalwith a subarachnoid brain attack (stroke). The client’s Glasgow Co
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maScale (GCS)score is9. Whatinformation is most importantforthenursetodetermine?
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• When the client’sstroke symptoms started
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• Iftheclient isorientedtotime
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• Theclient’sbloodpressureandrespiration rate w
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• Rationale: The normal GCS is 15, and it is most important for thenurseto det er
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mine if it abnormal score a sign of improvement or a deterioration in the cli ent’s
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condition
6. The charge nurse in a critical careunitisreviewingclients’conditions todeterminewhois stab
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le enough to be transferred. Which client status report indicates readiness for transfer from th
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e critical care unit to a medical unit?
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• Chronicliverfailurewith ahemoglobin of10.1and slightbilirubin elevation
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7. Basedonprinciplesofasepsis,thenurseshould considerwhichcircumstancetobesterile?
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• Oneinch-border aroundtheedgeofthe sterilefield set upin theoperating room
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• Awrappedunopened, sterile 4x4 gauzeplaced on adamptable top. sw sw vc w
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• Sterilesyringe isplacedonsterilearea as thenurserichesoverthesterilefield.
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• Rationale:Asterilepackageat or abovethe waist levelisconsideredsterile.The edg e o w
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f sterile field is contaminated which include a 1-
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inch border (A).Asterile objects become contaminatedbycapillaryactionwhenste ri
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leobjects become in contact with a wet contaminated surface.
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8. An unlicensedassistive personnel(UAP) reports that a client’s righthand and fingers spasms wh en t
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aking the blood pressure using the same arm.After confirming the presence of spams what a ction s
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hould the nurse take? sw sw sw




• Ask the UAP totaketheblood pressurein theotherarm
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, • Tellthe UAP touseadifferent sphygmomanometer.
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• AdministerPRNantianxietymedication. w
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• Rationale: Trousseau’s sign is indicated by spasms in the distal portion of an ext
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remitythat is being used tomeasurebloodpressureand iscausedby hypoc alcemia
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(normal level 9.0-10.5 mg/dl, so C should be implemented.
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9. A56-years-
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old man shares with thenursethat he is having difficulty makingdecisionabout terminating life support
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for his wife. What is the best initial action by the nurse?
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• Encouragehimtoshare memoriesabouthislifewithhiswifeandfamily sw w
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• Advisehimto seek several opinions before making decision
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• Offer tocontact thehospitalchaplain orsocial worker tooffer support.
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• Rationale:Whenaclient is faced withadecisional conflict, the nurse should first pro vi
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deopportunities forthe clientto clarifyvalues important inthedecision. The rest mayal
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so be beneficial oncethe client as clarified thevalues that areimportant to hi m in the de
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cision-making process. sw




10. A client is being discharged homeafter being treated forheartfailure(HF).Whatinstruction sho u
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ld the nurse include in this client’s discharge teaching plan?
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• Eata high protein diet
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• Performrange ofmotion exercises sw sw sw




• Limitfluid intake to1,500 ml daily
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11. Awoman justlearned that shewasinfected with Heliobacter pylori. Based onthisfinding, whi c vc sw sw sw sw sw sw sw sw




h health promotion practice should the nurse suggest?
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• Encourage screening for apeptic ulcer vc sw sw




12. A client who recentlyunderweara tracheostomyisbeingpreparedfordischargetohome. Wh ic
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h instructions is most important for the nurse to include in the discharge plan?
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• Teachtrachealsuctioning techniques vc




13. A child withheartfailureisreceivingthediuretic furosemide(Lasix) and hasserum pot as
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sium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?
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• Dailyintakeof foodsrich in potassium. w
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