HESI PN EXIT EXAM V3
2025/2026 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.
, HESI PN EXIT EXAM V3
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
, HESI PN EXIT EXAM V3
• Tell the UAP to use a different sphygmomanometer.
• Review the client’s serum calcium level
• Administer PRN antianxiety medication.
• 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 (normal level 9.0-10.5 mg/dl, so C should be implemented.
9. A 56-years-old fman fshares fwith fthe fnurse fthat fhe fis fhaving fdifficulty fmaking fdecision
fabout fterminating flife fsupport ffor fhis fwife. fWhat fis fthe fbest finitial faction fby fthe
fnurse?
• Provide fan fopportunity ffor fhim fto fclarify fhis fvalues frelated fto fthe fdecision
• Encourage fhim fto fshare fmemories fabout fhis flife fwith fhis fwife fand ffamily
• Advise fhim fto fseek fseveral fopinions fbefore fmaking fdecision
• Offer fto fcontact fthe fhospital fchaplain for fsocial fworker fto foffer fsupport.
• Rationale: fWhen fa fclient fis ffaced fwith fa fdecisional fconflict, fthe fnurse fshould
ffirst fprovide fopportunities ffor fthe fclient fto fclarify fvalues fimportant fin fthe
fdecision. fThe frest fmay falso fbe fbeneficial fonce fthe fclient fas fclarified fthe
fvalues fthat fare fimportant fto fhim fin fthe fdecision-making fprocess.
10. A fclient fis fbeing fdischarged fhome fafter fbeing ftreated ffor fheart ffailure f(HF). fWhat
finstruction fshould fthe fnurse finclude fin fthis fclient’s fdischarge fteaching fplan?
• Weigh fevery fmorning
• Eat fa fhigh fprotein fdiet
• Perform frange fof fmotion fexercises
• Limit ffluid fintake fto f1,500 fml fdaily
11. A fwoman fjust flearned fthat fshe fwas finfected fwith fHeliobacter fpylori. fBased fon fthis
ffinding, fwhich fhealth fpromotion fpractice fshould fthe fnurse fsuggest?
• Encourage fscreening ffor fa fpeptic fulcer
12. A fclient fwho frecently funderwear fa ftracheostomy fis fbeing fprepared ffor fdischarge fto
fhome. fWhich finstructions fis fmost fimportant ffor fthe fnurse fto finclude fin fthe
fdischarge fplan?
• Teach ftracheal fsuctioning ftechniques
13. A fchild fwith fheart ffailure fis freceiving fthe fdiuretic ffurosemide f(Lasix) fand fhas
fserum fpotassium flevel f3.0 fmEq/L. fWhich fassessment fis fmost fimportant ffor fthe
fnurse fto fobtain?
• Cardiac frhythm fand fheart frate.
• Daily fintake fof ffoods frich fin fpotassium.
2025/2026 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.
, HESI PN EXIT EXAM V3
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
, HESI PN EXIT EXAM V3
• Tell the UAP to use a different sphygmomanometer.
• Review the client’s serum calcium level
• Administer PRN antianxiety medication.
• 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 (normal level 9.0-10.5 mg/dl, so C should be implemented.
9. A 56-years-old fman fshares fwith fthe fnurse fthat fhe fis fhaving fdifficulty fmaking fdecision
fabout fterminating flife fsupport ffor fhis fwife. fWhat fis fthe fbest finitial faction fby fthe
fnurse?
• Provide fan fopportunity ffor fhim fto fclarify fhis fvalues frelated fto fthe fdecision
• Encourage fhim fto fshare fmemories fabout fhis flife fwith fhis fwife fand ffamily
• Advise fhim fto fseek fseveral fopinions fbefore fmaking fdecision
• Offer fto fcontact fthe fhospital fchaplain for fsocial fworker fto foffer fsupport.
• Rationale: fWhen fa fclient fis ffaced fwith fa fdecisional fconflict, fthe fnurse fshould
ffirst fprovide fopportunities ffor fthe fclient fto fclarify fvalues fimportant fin fthe
fdecision. fThe frest fmay falso fbe fbeneficial fonce fthe fclient fas fclarified fthe
fvalues fthat fare fimportant fto fhim fin fthe fdecision-making fprocess.
10. A fclient fis fbeing fdischarged fhome fafter fbeing ftreated ffor fheart ffailure f(HF). fWhat
finstruction fshould fthe fnurse finclude fin fthis fclient’s fdischarge fteaching fplan?
• Weigh fevery fmorning
• Eat fa fhigh fprotein fdiet
• Perform frange fof fmotion fexercises
• Limit ffluid fintake fto f1,500 fml fdaily
11. A fwoman fjust flearned fthat fshe fwas finfected fwith fHeliobacter fpylori. fBased fon fthis
ffinding, fwhich fhealth fpromotion fpractice fshould fthe fnurse fsuggest?
• Encourage fscreening ffor fa fpeptic fulcer
12. A fclient fwho frecently funderwear fa ftracheostomy fis fbeing fprepared ffor fdischarge fto
fhome. fWhich finstructions fis fmost fimportant ffor fthe fnurse fto finclude fin fthe
fdischarge fplan?
• Teach ftracheal fsuctioning ftechniques
13. A fchild fwith fheart ffailure fis freceiving fthe fdiuretic ffurosemide f(Lasix) fand fhas
fserum fpotassium flevel f3.0 fmEq/L. fWhich fassessment fis fmost fimportant ffor fthe
fnurse fto fobtain?
• Cardiac frhythm fand fheart frate.
• Daily fintake fof ffoods frich fin fpotassium.
