HESI PN EXIT EXAM V3

Question 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)? Options: 1. 9% 2. 18% 3. 36% 4. 45% - Answer: 36%<br> Rationale: According to the rule of nines, the anterior and posterior surfaces of one lower extremity are designated as 18% of total body surface area (TBSA), so both extremities equal 36% TBSA. The other options are incorrect. Question 2: A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect? Options: 1. Decrease in serum T4 levels 2. Increase in blood pressure 3. Decrease in pulse rate 4. Goiter no longer palpable - Answer: Decrease in pulse rate<br> Rationale: Propranolol is a beta-blocker medication used to treat hyperthyroidism. One of its effects is to decrease heart rate. The other options are unrelated to the desired effect of the medication. Question 3: An older male client with type 2 diabetes mellitus reports that he experiences leg 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? Options: 1. Consistently applies TED hose before getting dressed in the morning. 2. Frequently elevates legs throughout the day. 3. Inspects the leg frequently for any irritation or skin breakdown 4. Completely stops cigarette/cigar smoking. - Answer: Completely stops cigarette/cigar smoking.<br> Rationale: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremities. The other options are not directly related to arterial circulation. Question 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? Options: Establish trust with community leaders and respect cultural and family values - Answer: Establish trust with community leaders and respect cultural and family values. Question 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? Options: 1. The client's previous GCS score 2. When the client's stroke symptoms started 3. If the client is oriented to time 4. The client's blood pressure and respiration rate - Answer: The client's previous GCS score<br> Rationale: The normal GCS is 15, and it is most important for the nurse to determine if the abnormal score is a sign of improvement or a deterioration in the client's condition. Question 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? Options: Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation - Answer: Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation. Question 7: Based on principles of asepsis, the nurse should consider which circumstance to be sterile? Options: 1. One-inch border around the edge of the sterile field set up in the operating room 2. A wrapped unopened, sterile 4x4 gauze placed on a damp tabletop. 3. An open sterile Foley catheter kit set up on a table at the nurse's waist level 4. Sterile syringe is placed on a sterile area as the nurse reaches over the sterile field. - Answer: A sterile syringe is placed on a sterile area as the nurse reaches over the sterile field.<br> Rationale: A sterile package at or above the waist level is considered sterile. The edge of the sterile field is contaminated, including a 1-inch border. A sterile object becomes contaminated by capillary action when it comes in contact with a wet contaminated surface. Question 8: An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of spasms, what action should the nurse take? Options: 1. Ask the UAP to take the blood pressure in the other arm 2. Tell the UAP to use a different sphygmomanometer 3. Review the client's serum calcium level 4. Administer PRN antianxiety medication - Answer: Review the client's serum calcium level.<br> Rationale: Trousseau's sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia. The nurse should review the client's serum calcium level. Question 9: A 56-year-old man shares with the nurse that he is having difficulty making decisions about terminating life support for his wife. What is the best initial action by the nurse? Options: 1. Provide an opportunity for him to clarify his values related to the decision 2. Encourage him to share memories about his life with his wife and family 3. Advise him to seek several opinions before making a decision 4. Offer to contact the hospital chaplain or social worker to offer support - Answer: Provide an opportunity for him to clarify his values related to the decision.<br> Rationale: When a client is faced with a decisional conflict, the nurse should first provide opportunities for the client to clarify values important in the decision. The other options may also be beneficial once the client has clarified the values that are important to him in the decision-making process.