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EXIT HESI -PN EXAM A PRACTICE QUESTIONS
WITH VERIFIED ANSWERS
A nurse is planning patient care and wants to verify the steps for a specific client
procedure. Which action should the nurse take?
A.Review the plan and the steps in performing the procedure with another nurse.
B.Look up the specific procedure in a medical surgical nursing text on the unit.
C.Discuss the client's prescribed procedure with an available health care provider.
D.Consult the agency's policies and procedures manual and follow the
guidelines.-correct-answer-D
The agency's policies and procedures manual (D) should be consulted to verify the
agency's approved protocol for the client's procedure, which is adapted to follow
current standards of care. (A and B) may be resources, but client care should be
implemented according to the agency's published policies and procedures. (C) is
not practical.
The nurse would be correct in withholding a dose of digoxin in a client with
congestive heart failure without specific instruction from the health care provider
if which finding was documented?
A.Serum digoxin level is 1.5 ng/mL
B.Blood pressure is 104/68 mm Hg
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C.Serum potassium level is 2.5 mEq/L
D.Apical pulse is 68/min-correct-answer-C
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin,
which will increase the chance of dangerous dysrhythmias (normal potassium
level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic
levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the nurse
withholding the digoxin. The nurse should withhold the digoxin if the apical pulse
is less than 60/min (D).
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP.
Team 1's assignment includes two clients who are both 1 day postangioplasty and
two clients with unstable angina. Team 2's assignment includes all stable clients,
but two clients are bedridden and incontinent. Which staffing plan represents the
best use of available staff?
A.Team 1: RN team leader, PN; team 2, PN team leader, UAP
B.Team 1, RN team leader, UAP; team 2, PN team leader, PN
C.Team 1, PN team leader, PN; team 2, RN team leader, UAP
D.Team 1, PN team leader, UAP; team 2, RN team leader, PN-correct-answer-A
Team 1 includes high-risk clients who require a higher level of assessment and
decision making, which should be provided by an RN and PN (A). Team 2 has
stable clients at lower risk than those on team 1. Although two clients on team 2
require frequent care, the care is routine and predictable in nature and can be
managed by the PN and UAP. (B, C, and D) do not use the expertise of the nursing
staff for the high-risk clients.
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The nurse formulates a nursing diagnosis of pain related to muscle spasms for a
client with extreme lower back pain associated with acute lumbosacral strain.
Which is the best intervention for the nurse to implement?
A.Perform range-of-motion exercises on the lower extremities every 4 hours.
B.Place a small firm pillow under the upper back to flex the lumbar spine gently.
C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees.
D.Position in reverse Trendelenburg with the feet firmly against the foot of the
bed.-correct-answer-C
Resting in bed with the head of the bed elevated 20 degrees and flexing the knees
reduces stress on the lower back muscles (C). Range-of-motion exercises can
result in paravertebral muscle spasms and increased pain (A). Bending the knees,
rather than (B), reduces stress on the lower back. (D) places stress on the lower
back and increases the client's pain.
The nurse plans to evaluate the effectiveness of a bronchodilator. Which
assessment datum indicates that the desired effect of a bronchodilator has been
achieved?
A.Increased oxygen saturation
B.Increased urinary output
C.Decreased apical pulse rate
D.Decreased blood pressure-correct-answer-A
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Bronchodilators increase the diameter of the bronchioles, resulting in improved
oxygenation, reflected by an increase in oxygen saturation (A). (B, C, and D) do not
indicate the desired effect of a bronchodilator
A client with hemiparesis needs assistance transferring from the bed to the
wheelchair. The nurse assists the client to a sitting position on the side of the bed.
Which action should the nurse implement next?
A.Flex the hips and knees and align the knees with the client's knees for safety.
B.Allow the client to sit on the side of the bed for a few minutes before
transferring.
C.Place the client's weight-bearing or strong leg forward and the weak foot back.
D.Grasp the transfer belt at the client's sides to provide movement of the client.-
correct-answer-B
A client who has been immobile may be weak and dizzy and develop orthostatic
hypotension (a drop in blood pressure on rising), so allowing the client to sit for a
few minutes (B) before transferring from the bedside to the wheelchair provides
time for the client to gain equilibrium and allows dependent blood in the lower
extremities to return to the heart. Next, positioning the legs under the client's
center of gravity (A and C) reduces back strain and stabilizes the client to stand. To
ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a
transfer belt (D) provides a secure hold to prevent sudden falls.
When the nurse-manager posts a schedule for volunteers to be on call, one staff
member immediately signs up for all available 7-to-3 day shifts. Other staff
members complain to the charge nurse that they were not permitted the
EXIT HESI -PN EXAM A PRACTICE QUESTIONS
WITH VERIFIED ANSWERS
A nurse is planning patient care and wants to verify the steps for a specific client
procedure. Which action should the nurse take?
A.Review the plan and the steps in performing the procedure with another nurse.
B.Look up the specific procedure in a medical surgical nursing text on the unit.
C.Discuss the client's prescribed procedure with an available health care provider.
D.Consult the agency's policies and procedures manual and follow the
guidelines.-correct-answer-D
The agency's policies and procedures manual (D) should be consulted to verify the
agency's approved protocol for the client's procedure, which is adapted to follow
current standards of care. (A and B) may be resources, but client care should be
implemented according to the agency's published policies and procedures. (C) is
not practical.
The nurse would be correct in withholding a dose of digoxin in a client with
congestive heart failure without specific instruction from the health care provider
if which finding was documented?
A.Serum digoxin level is 1.5 ng/mL
B.Blood pressure is 104/68 mm Hg
,2|Page
C.Serum potassium level is 2.5 mEq/L
D.Apical pulse is 68/min-correct-answer-C
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin,
which will increase the chance of dangerous dysrhythmias (normal potassium
level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic
levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the nurse
withholding the digoxin. The nurse should withhold the digoxin if the apical pulse
is less than 60/min (D).
Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP.
Team 1's assignment includes two clients who are both 1 day postangioplasty and
two clients with unstable angina. Team 2's assignment includes all stable clients,
but two clients are bedridden and incontinent. Which staffing plan represents the
best use of available staff?
A.Team 1: RN team leader, PN; team 2, PN team leader, UAP
B.Team 1, RN team leader, UAP; team 2, PN team leader, PN
C.Team 1, PN team leader, PN; team 2, RN team leader, UAP
D.Team 1, PN team leader, UAP; team 2, RN team leader, PN-correct-answer-A
Team 1 includes high-risk clients who require a higher level of assessment and
decision making, which should be provided by an RN and PN (A). Team 2 has
stable clients at lower risk than those on team 1. Although two clients on team 2
require frequent care, the care is routine and predictable in nature and can be
managed by the PN and UAP. (B, C, and D) do not use the expertise of the nursing
staff for the high-risk clients.
,3|Page
The nurse formulates a nursing diagnosis of pain related to muscle spasms for a
client with extreme lower back pain associated with acute lumbosacral strain.
Which is the best intervention for the nurse to implement?
A.Perform range-of-motion exercises on the lower extremities every 4 hours.
B.Place a small firm pillow under the upper back to flex the lumbar spine gently.
C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees.
D.Position in reverse Trendelenburg with the feet firmly against the foot of the
bed.-correct-answer-C
Resting in bed with the head of the bed elevated 20 degrees and flexing the knees
reduces stress on the lower back muscles (C). Range-of-motion exercises can
result in paravertebral muscle spasms and increased pain (A). Bending the knees,
rather than (B), reduces stress on the lower back. (D) places stress on the lower
back and increases the client's pain.
The nurse plans to evaluate the effectiveness of a bronchodilator. Which
assessment datum indicates that the desired effect of a bronchodilator has been
achieved?
A.Increased oxygen saturation
B.Increased urinary output
C.Decreased apical pulse rate
D.Decreased blood pressure-correct-answer-A
, 4|Page
Bronchodilators increase the diameter of the bronchioles, resulting in improved
oxygenation, reflected by an increase in oxygen saturation (A). (B, C, and D) do not
indicate the desired effect of a bronchodilator
A client with hemiparesis needs assistance transferring from the bed to the
wheelchair. The nurse assists the client to a sitting position on the side of the bed.
Which action should the nurse implement next?
A.Flex the hips and knees and align the knees with the client's knees for safety.
B.Allow the client to sit on the side of the bed for a few minutes before
transferring.
C.Place the client's weight-bearing or strong leg forward and the weak foot back.
D.Grasp the transfer belt at the client's sides to provide movement of the client.-
correct-answer-B
A client who has been immobile may be weak and dizzy and develop orthostatic
hypotension (a drop in blood pressure on rising), so allowing the client to sit for a
few minutes (B) before transferring from the bedside to the wheelchair provides
time for the client to gain equilibrium and allows dependent blood in the lower
extremities to return to the heart. Next, positioning the legs under the client's
center of gravity (A and C) reduces back strain and stabilizes the client to stand. To
ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a
transfer belt (D) provides a secure hold to prevent sudden falls.
When the nurse-manager posts a schedule for volunteers to be on call, one staff
member immediately signs up for all available 7-to-3 day shifts. Other staff
members complain to the charge nurse that they were not permitted the
