EXIT HESI PN TEST PAPER ANSWERS AND
QUESTIONS SET A+
✔✔A mother of a 12-year-old boy states that her son is short and she fears that he will
always be shorter than his peers. She tells the nurse that her grown daughter only grew
2 inches after she was 12 years of age. To provide health teaching, which question is
most important for the nurse to ask this mother?
A."Is your son's short stature a social embarrassment to him or the family?"
B."What types of foods do both your children eat now and what did they eat when they
were infants?"
C."Did any significant trauma occur with the birth of your son?"
D."Did your daughter also start her menstrual period at 12 years of age?" - ✔✔D
Girls are expected to mature sexually and grow physically sooner than boys.
Furthermore, girls only grow an average of 2 inches after menses begins (D). (A) is not
appropriate at this time. The mother is worried that something is wrong with her son
physically. (B) has less to do with stature than growth and development. (C) is not
related to growth hormone deficiencies, which are idiopathic (without known causes).
✔✔The nurse calls the primary health care provider to report the status of a postsurgical
client. Place the statements in the correct SBAR communication format.
A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P
150/88, HR 90, and RR 26, with an O2 sat of 95%."
B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital."
C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain
control with his current medication regimen since the surgery."
D. "Would you like to make a change in his pharmacologic regimen?"
A. C, B, A, D
B. B, C, A, D
C. A, B, C, D
D. A, C, D, B - ✔✔B
SBAR:
S = Situation and includes introduction of the nurse and client/setting (B).
, B = Background and includes the presenting complaint and relevant history (C).
A = Assessment and includes current vital signs and other information (A).
R = Recommendations and includes an explanation of why you are calling or a
suggestion about which action should be taken (D).
✔✔A client with rhabdomyolysis tells the nurse about falling while going to the bathroom
and lying on the floor for 24 hours before being found. Which current client finding is
indicative of renal complications?
A.3+ protein in the urine
B.Blood urea nitrogen >25 mg/dL
C.Blood pH >7.45
D.Urine output, 2500 mL/day - ✔✔B
Rhabdomyolysis is characterized by destruction of muscles that release myoglobin,
causing myoglobinuria, which places the client at risk for acute renal failure, so an
increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function.
Blood in the urine from the accompanying breakdown of red blood cells contributes to
proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not
alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal
output volume (D) (approximately 2000 mL/day), which can result from IV fluid
hydration.
✔✔What instruction(s) related to foot care is(are) appropriate for the client with type 1
diabetes mellitus? (Select all that apply.)
A.Use lanolin to moisturize the tops and bottoms of the feet.
B.Soak the feet in warm water for at least 1 hour daily.
C.Wash feet daily and dry well, particularly between the toes.
D.Use over-the-counter products to remove corns and calluses.
E.Wear leather shoes that fit properly. - ✔✔ACE
(A, C, and E) are therapeutic interventions for foot care in the diabetic patient. (B and D)
are contraindicated and could cause foot infection or injury.
✔✔The nurse recognizes which behavior(s) in a client as warning sign(s) of an
impending suicide attempt? (Select all that apply.)
A.Reports feelings of sadness
B.Mood changes from depressed to happy
C.Begins giving away possessions
D.Becomes compliant with medication regimen
E.Independently joins a support group - ✔✔BC
Feelings of elation and giving away possessions are common characteristics of those
who have made a plan to commit suicide (B and C). Feelings of sadness are signs of
depression but not impending suicide (A). (D and E) are not typically indicative of
impending suicide.
QUESTIONS SET A+
✔✔A mother of a 12-year-old boy states that her son is short and she fears that he will
always be shorter than his peers. She tells the nurse that her grown daughter only grew
2 inches after she was 12 years of age. To provide health teaching, which question is
most important for the nurse to ask this mother?
A."Is your son's short stature a social embarrassment to him or the family?"
B."What types of foods do both your children eat now and what did they eat when they
were infants?"
C."Did any significant trauma occur with the birth of your son?"
D."Did your daughter also start her menstrual period at 12 years of age?" - ✔✔D
Girls are expected to mature sexually and grow physically sooner than boys.
Furthermore, girls only grow an average of 2 inches after menses begins (D). (A) is not
appropriate at this time. The mother is worried that something is wrong with her son
physically. (B) has less to do with stature than growth and development. (C) is not
related to growth hormone deficiencies, which are idiopathic (without known causes).
✔✔The nurse calls the primary health care provider to report the status of a postsurgical
client. Place the statements in the correct SBAR communication format.
A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P
150/88, HR 90, and RR 26, with an O2 sat of 95%."
B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital."
C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain
control with his current medication regimen since the surgery."
D. "Would you like to make a change in his pharmacologic regimen?"
A. C, B, A, D
B. B, C, A, D
C. A, B, C, D
D. A, C, D, B - ✔✔B
SBAR:
S = Situation and includes introduction of the nurse and client/setting (B).
, B = Background and includes the presenting complaint and relevant history (C).
A = Assessment and includes current vital signs and other information (A).
R = Recommendations and includes an explanation of why you are calling or a
suggestion about which action should be taken (D).
✔✔A client with rhabdomyolysis tells the nurse about falling while going to the bathroom
and lying on the floor for 24 hours before being found. Which current client finding is
indicative of renal complications?
A.3+ protein in the urine
B.Blood urea nitrogen >25 mg/dL
C.Blood pH >7.45
D.Urine output, 2500 mL/day - ✔✔B
Rhabdomyolysis is characterized by destruction of muscles that release myoglobin,
causing myoglobinuria, which places the client at risk for acute renal failure, so an
increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function.
Blood in the urine from the accompanying breakdown of red blood cells contributes to
proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not
alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal
output volume (D) (approximately 2000 mL/day), which can result from IV fluid
hydration.
✔✔What instruction(s) related to foot care is(are) appropriate for the client with type 1
diabetes mellitus? (Select all that apply.)
A.Use lanolin to moisturize the tops and bottoms of the feet.
B.Soak the feet in warm water for at least 1 hour daily.
C.Wash feet daily and dry well, particularly between the toes.
D.Use over-the-counter products to remove corns and calluses.
E.Wear leather shoes that fit properly. - ✔✔ACE
(A, C, and E) are therapeutic interventions for foot care in the diabetic patient. (B and D)
are contraindicated and could cause foot infection or injury.
✔✔The nurse recognizes which behavior(s) in a client as warning sign(s) of an
impending suicide attempt? (Select all that apply.)
A.Reports feelings of sadness
B.Mood changes from depressed to happy
C.Begins giving away possessions
D.Becomes compliant with medication regimen
E.Independently joins a support group - ✔✔BC
Feelings of elation and giving away possessions are common characteristics of those
who have made a plan to commit suicide (B and C). Feelings of sadness are signs of
depression but not impending suicide (A). (D and E) are not typically indicative of
impending suicide.
