HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWERS (CORRECTLY VERIFIED ANSWERS)

HESI PN EXIT EXAM
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V3 110 QUESTIONS
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AND ANSWERS
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(CORRECTLY i




VERIFIEDANSWERS) i

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




1. Ani adulti clienti experiencesi ai gasolinei tanki firei wheni ridingi ai motorcyclei andi isi admittedi toi
thei emergencyi departmenti (ED)i withi fulli thicknessi burnsi toi alli surfacesi ofi bothi loweri
extremities.i Whati percentagei ofi bodyi surfacei areai shouldi thei nursei documenti ini thei
electronici medicali recordi (EMR)?
i 9i %
i 18i %
i 36i %
i 45i %
i Rational:i accordingi toi thei rulei ofi nines,i thei anteriori andi posteriori surfacesi ofi onei
loweri extremityi isi designatedi asi 18i %ofi totali bodyi surfacei areai (TBSA),i soi bothi
extremitiesi equalsi 36%i TBSA,i otheri optionsi arei incorrect.
2. Ai clienti withi hyperthyroidismi isi receivingi propranololi (Inderal).i Whichi findingi indicatesi thati
thei medicationi isi havingi thei desiredi effect?
i Decreasei ini serumi T4i levels
i Increasei ini bloodi pressure
i Decreasei ini pulsei rate
i Goiteri noi longeri palpable
3. Ani olderi malei clienti withi typei 2i diabetesi mellitusi reportsi thati hasi experiencesi legsi paini
wheni walkingi shorti distances,i andi thati thei paini isi relievedi byi rest.i Whichi clienti behaviori
indicatesi ani understandingi ofi healthcarei teachingi toi promotei morei effectivei arteriali
circulation?
i Consistentlyi appliesi TEDi hosei beforei gettingi dressedi ini thei morning.
i Frequentlyi elevatedi legsi thoroughi thei day.
i Inspecti thei legi frequentlyi fori anyi irritationi ori skini breakdown
i Completelyi stopi cigarette/i cigari smoking.
i Rationale:i Stoppingi cigarettei smokingi helpsi toi decreasei vasoconstrictioni andi
improvei arteriali circulationi toi thei extremity.

,4. Ai communityi healthi nursei isi concernedi abouti thei spreadi ofi communicablei diseasesi amongi
migranti farmi workersi ini ai rurali community.i Whati actioni shouldi thei nursei takei toi promotei thei
successi ofi ai healthcarei programi designedi toi addressi thisi problem?
Establishi trusti withi communityi leadersi andi respecti culturali andi familyi values
5. Thei nursei performsi ai prescribedi neurologicali checki ati thei beginningi ofi thei shifti oni ai clienti
whoi wasi admittedi toi thei hospitali withi ai subarachnoidi braini attacki (stroke).i Thei client’si
Glasgowi Comai Scalei (GCS)i scorei isi 9.i Whati informationi isi mosti importanti fori thei nursei toi
determine?
i Thei client’si previousi GCSi score
i Wheni thei client’si strokei symptomsi started
i Ifi thei clienti isi orientedi toi time
i Thei client’si bloodi pressurei andi respirationi rate
i Rationale:i Thei normali GCSi isi 15,i andi iti isi mosti importanti fori thei nursei toi
determinei ifi iti abnormali scorei ai signi ofi improvementi ori ai deteriorationi ini thei
client’si condition
6. Thei chargei nursei ini ai criticali carei uniti isi reviewingi clients’i conditionsi toi determinei whoi isi
stablei enoughi toi bei transferred.i Whichi clienti statusi reporti indicatesi readinessi fori transferi
fromi thei criticali carei uniti toi ai medicali unit?
Chronici liveri failurei withi ai hemoglobini ofi 10.1i andi slighti bilirubini elevation
7. Basedi oni principlesi ofi asepsis,i thei nursei shouldi consideri whichi circumstancei toi bei sterile?
i Onei inch-i borderi aroundi thei edgei ofi thei sterilei fieldi seti upi ini thei operatingi room
i Ai wrappedi unopened,i sterilei 4x4i gauzei placedi oni ai dampi tablei top.
i Ani openi sterilei Foleyi catheteri kiti seti upi oni ai tablei ati thei nursei waisti leveli
i Sterilei syringei isi placedi oni sterilei areai asi thei nursei richesi overi thei sterilei field.
i Rationale:i Ai sterilei packagei ati ori abovei thei waisti leveli isi consideredi sterile.i Thei
edgei ofi sterilei fieldi isi contaminatedi whichi includei ai 1-inchi borderi (A).i Ai sterilei
objectsi becomei contaminatedi byi capillaryi actioni wheni sterilei objectsi becomei ini
contacti withi ai weti contaminatedi surface.
8. Ani unlicensedi assistivei personneli (UAP)i reportsi thati ai client’si righti handi andi fingersi spasmsi
wheni takingi thei bloodi pressurei usingi thei samei arm.i Afteri confirmingi thei presencei ofi spamsi
whati actioni shouldi thei nursei take?
i Aski thei UAPi toi takei thei bloodi pressurei ini thei otheri arm

, i Telli thei UAPi toi usei ai differenti sphygmomanometer.
i Reviewi thei client’si serumi calciumi level
i Administeri PRNi antianxietyi medication.
i Rationale:i Trousseau’si signi isi indicatedi byi spasmsi ini thei distali portioni ofi ani
extremityi thati isi beingi usedi toi measurei bloodi pressurei andi isi causedi byi
hypocalcemiai (normali leveli 9.0-10.5i mg/dl,i soi Ci shouldi bei implemented.
9. Ai 56-years-oldi mani sharesi withi thei nursei thati hei isi havingi difficultyi makingi decisioni abouti
terminatingi lifei supporti fori hisi wife.i Whati isi thei besti initiali actioni byi thei nurse?
i Providei ani opportunityi fori himi toi clarifyi hisi valuesi relatedi toi thei decision
i Encouragei himi toi sharei memoriesi abouti hisi lifei withi hisi wifei andi family
i Advisei himi toi seeki severali opinionsi beforei makingi decision
i Offeri toi contacti thei hospitali chaplaini ori sociali workeri toi offeri support.
i Rationale:i Wheni ai clienti isi facedi withi ai decisionali conflict,i thei nursei shouldi firsti
providei opportunitiesi fori thei clienti toi clarifyi valuesi importanti ini thei decision.i Thei
resti mayi alsoi bei beneficiali oncei thei clienti asi clarifiedi thei valuesi thati arei importanti
toi himi ini thei decision-makingi process.
10. Ai clienti isi beingi dischargedi homei afteri beingi treatedi fori hearti failurei (HF).i Whati instructioni
shouldi thei nursei includei ini thisi client’si dischargei teachingi plan?
i Weighi everyi morning
i Eati ai highi proteini diet
i Performi rangei ofi motioni exercises
i Limiti fluidi intakei toi 1,500i mli daily
11. Ai womani justi learnedi thati shei wasi infectedi withi Heliobacteri pylori.i Basedi oni thisi finding,i
whichi healthi promotioni practicei shouldi thei nursei suggest?
Encouragei screeningi fori ai peptici ulcer
12. Ai clienti whoi recentlyi underweari ai tracheostomyi isi beingi preparedi fori dischargei toi home.i
Whichi instructionsi isi mosti importanti fori thei nursei toi includei ini thei dischargei plan?
Teachi tracheali suctioningi techniques
13. Ai childi withi hearti failurei isi receivingi thei diuretici furosemidei (Lasix)i andi hasi serumi
potassiumi leveli 3.0i mEq/L.i Whichi assessmenti isi mosti importanti fori thei nursei toi obtain?
i Cardiaci rhythmi andi hearti rate.
i Dailyi intakei ofi foodsi richi ini potassium.