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

1. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? □ 9 % □ 18 % • 36 % □ 45 % □ Rational: according to the rule of nines, the anterior and posterior surfaces of one lower extremity is designated as 18 %of total body surface area (TBSA), so both extremities equals 36% TBSA, other options are incorrect. 2. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? □ Decrease in serum T4 levels □ Increase in blood pressure • Decrease in pulse rate □ Goiter no longer palpable 3. An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? □ Consistently applies TED hose before getting dressed in the morning. □ Frequently elevated legs thorough the day. □ Inspect the leg frequently for any irritation or skin breakdown • Completely stop cigarette/ cigar smoking. □ Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity. 4. A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? • Establish trust with community leaders and respect cultural and family values 5. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? • The client’s previous GCS score □ When the client’s stroke symptoms started □ If the client is oriented to time □ The client’s blood pressure and respiration rate □ Rationale: The normal GCS is 15, and it is most important for the nurse to determine if it abnormal score a sign of improvement or a deterioration in the client’s condition 6. The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? • Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation 7. Based on principles of asepsis, the nurse should consider which circumstance to be sterile? □ One inch- border around the edge of the sterile field set up in the operating room □ A wrapped unopened, sterile 4x4 gauze placed on a damp table top. • An open sterile Foley catheter kit set up on a table at the nurse waist level □ Sterile syringe is placed on sterile area as the nurse riches over the sterile field. □ Rationale: A sterile package at or above the waist level is considered sterile. The edge of sterile field is contaminated which include a 1-inch border (A). A sterile objects become contaminated by capillary action when sterile objects become in contact with a wet contaminated surface. 8. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? □ Ask the UAP to take the blood pressure in the other arm