HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
HESI PN EXIT PRACTICE QS
Thevgpracticalvgnursevg(PN)vgisvgcaringvgforvgavgclientvgwithvgGraves'vgdisease.vgThevgPNvgshouldvgexpectvgwhichvgfindingsvg
withvgthisvgclient?vg-vganswer--
CharacteristicsvgofvgGraves'vgdiseasevgincludevgexophthalmos,vgheatvgintolerance,vgandvgsoftvgsmoothvgskinvgandvghairvgin
vgadditionvgtovgweightvgloss,vgnervousness,vgandvgfinevgtremorsvgofvgthevghands.
Avgclientvghasvgavgserumvgpotassiumvglevelvgofvg3vgmEq/
L.vgWhichvgfindingsvgshouldvgthevgpracticalvgnursevgreportvgtovgthevgchargevgnurse?vg
(Selectvgallvgthatvgapply.)
A.vgMusclevgcramps
B.vgDiarrhea
C.vgAlteredvgbloodvgglucosevglevel
D.vgIncreasedvgenergy
E.vgAbnormalvgheartvgrhythms
F.vgIncreasedvganxietyvg-vganswer--A.vgMusclevgcramps
E.vgAbnormalvgheartvgrhythms
Rationale:vgAvgnormalvgpotassiumvglevelvgrangesvgfromvg3.5vgtovg5vgmEq/Lvg(mmol/
L).vgSignsvgandvgsymptomsvgofvglowvgpotassiumvgincludevgmusclevgcrampsvgandvgdysrhythmias.
Avgclientvgdiagnosedvgwithvgdiabetesvgmellitusvgcomplainsvgofvgvomitingvgandvgfeelingvgconfusedvgtovgthevgpracticalvgnurse.
vgWhichvgofvgthevgfollowingvgsymptomsvgarevgpossiblevgsignsvgofvgdiabeticvgketoacidosisvg(DKA)?
vg(Selectvgallvgthatvgapply.)
A.vgFruityvgbreathvgodor
B.vgRapid,vgweakvgpulse
C.vgCold,vgclammyvgskin
D.vgExtremevgthirst
E.vgUrinaryvgfrequency
F.vgProtrudingvgeyeballsvg-vganswer--A.vgFruityvgbreathvgodor
B.vgRapid,vgweakvgpulse
D.vgExtremevgthirst
E.vgUrinaryvgfrequency
Rationale:vgDiabeticvgketoacidosisvgisvgcausedvgbyvgavgprofoundvgdeficiencyvgofvginsulin.vgSomevgcommonvgcharacteristic
svgincludevgavgsweet,vgfruityvgbreathvgodor;vgavgrapidvgweakvgpulse;vgextremevgthirst;vgurinaryvgfrequency;vgandvgsunken-
appearingvgeyeballs.
Whatvgisvgthevgdepthvgofvgthevgcompressionvgthevgpracticalvgnursevg(PN)vgshouldvgdovgwhenvgperformingvgthevgmanualvgch
estvgcompressionsvgduringvgcardiopulmonaryvgresuscitationvg(CPR)vgonvganvgadultvgclient?
A.vg0.5vginchvg(1.27vgcm)vgtovg1vginchvg(2.54vgcm)
B.vg1.5vginchvg(3.8vgcm)vgtovg2vginchesvg(5vgcm)
C.vg2vginchesvg(5vgcm)vgtovg2.4vginchesvg(6vgcm)
1vg/
vg11
, HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
D.vg2.5vginchesvg(6.4vgcm)vgtovg3vginchesvg(7.6vgcm)vg-vganswer--C.vg2vginchesvg(5vgcm)vgtovg2.4vginchesvg(6vgcm
Rationale:vgAccordingvgtovgthevgAmericanvgHeartvgAssociationvg2015vgguidelines,vgthevgdepthvgofvgcompressionsvgonvganv
gadultvgduringvgCPRvgshouldvgbevgatvgleastvg2vginchesvg(5vgcm)vgtovg2.4vginchesvg(6vgcm).
Avgclientvgdiagnosedvgwithvgavgskullvghematomavgandvgfracturedvg(L)vgclaviclevgstatusvgpostvgavgsixvgfootvgfallvgfromvgavgladd
ervgisvgadmittedvgtovgthevgunit.vgWhichvgsignvgshouldvgthevgpracticalvgnursevg(PN)vgreportvgimmediately?
A.vgSpontaneouslyvgopensvgeyes
.B.vgObeysvgcommandsvginvgmovementvgandvggrip.
C.vgAnswersvgquestions,vgbutvgisvgconfused.
D.vgHasvgabnormalvgflexionvgorvgextensionvgofvg(L)vgarm.vg-vganswer--C.vgAnswersvgquestions,vgbutvgisvgconfused.
Rationale:vg"Thevgquestionvgaskvgwhichvgshouldvgbevgreportvgimmediately?"vgAnvgabnormalvgchangevginvgconditionvgrelate
dvgtovgDx.vgConfusionvgstatusvgpostvgavgheadvginjuryvgisvgusuallyvgthevgfirstvgsignvgofvgincreasedvgintracranialvgpressure.
Avgclientvgdiagnosedvgwithvgduodenalvgulcersvgisvgadmittedvgtovgthevghospital.vgThevgclientvgwasvgadministeredvgranitidinevg
hydrochloridevg150vgmgvgPOvgatvgbedtime.vgWhichvgfindingvgwouldvgindicatevgavgtherapeuticvgresponsevgofvgthevgmedicati
on?
A.vgGastricvgsecretionsvgpHvglevelvgbelowvg3.
B.vgHemoccultvgtestingvgisvgpositivevgonvgtwovgdifferentvgoccasions.
C.vgNovgdifficultyvgfallingvgasleepvgreported.
D.vgNovgcomplaintsvgofvgabdominalvgpainvgorvgheartburnvgverbalized.vg-vganswer--
D.vgNovgcomplaintsvgofvgabdominalvgpainvgorvgheartburnvgverbalized.
Rationale:vgItvgisvgaskingvgtovgindicatevgavgtherapeuticvgresponsevgofvgthevgmedication.vgsovgknowvgyourvgmedications.
Lackvgofvgabdominalvgpainvgwithinvg4vghoursvgaftervgmealsvgindicatesvgdecreasedvgduodenalvgirritation,vgavgpositivevgoutco
mevginvgthevgtreatmentvgofvgduodenalvgulcer.
Avgclientvgdiagnosedvgwithvgdiabetesvgcomplainsvgtovgthevgpracticalvgnursevgofvgdecreasedvgtactilevgsensationvginvgtheirvgfe
etvgandvgfeelingsvglikevgtheirvgfeetvgarevgonvgfirevgsometimes.vgWhichvgabnormalvglaboratoryvgfindingvgshouldvgthevgpractical
vgnursevg(PN)vgidentifyvgthatvgindicatesvgthatvgavgclientvgwithvgdiabetesvgneedsvgfurthervgevaluationvgforvgdiabeticvgnephropa
thy?
A.vgHypokalemia
B.vgMicroalbuminuria
C.vgElevatedvgserumvglipids
D.vgKetonuriavg-vganswer--
Rationale:vgMicroalbuminuriavgisvgthevgearliestvgsignvgofvgdiabeticvgnephropathyvgandvgindicatesvgthevgneedvgforvgfollow-
upvgevaluation.
Avgclientvgdiagnosedvgwithvglymphomavgisvgreceivingvgchemotherapy.vgThevgclient'svghemoglobinvgisvgcurrentlyvg6vgg/
dL.vgThevgpracticalvgnursevg(PN)vgassignsvganvgunlicensedvgassistivevgpersonnelvg(UAP)vgtovgprovidevgpersonalvghygienev
gforvgthisvgclient.vgWhatvginstructionvgshouldvgthevgPNvgprovidevgtovgthevgUAP?
A.vgReportvganyvgsignsvgofvgnauseavgorvgvomitingvgimmediately.
B.vgThevgclientvgwillvgbevgweakvgandvgunsteadyvgandvgtirevgeasily.
C.vgWatchvgcarefullyvgforvganyvgsignsvgofvgbleeding.
D.vgThevgclient'svgskinvgwillvgbevgfragilevgandvgbruisevgeasily.vg-vganswer--
B.vgThevgclientvgwillvgbevgweakvgandvgunsteadyvgandvgtirevgeasily.
2vg/
vg11
vg vg vg vg vg vg
onale)
HESI PN EXIT PRACTICE QS
Thevgpracticalvgnursevg(PN)vgisvgcaringvgforvgavgclientvgwithvgGraves'vgdisease.vgThevgPNvgshouldvgexpectvgwhichvgfindingsvg
withvgthisvgclient?vg-vganswer--
CharacteristicsvgofvgGraves'vgdiseasevgincludevgexophthalmos,vgheatvgintolerance,vgandvgsoftvgsmoothvgskinvgandvghairvgin
vgadditionvgtovgweightvgloss,vgnervousness,vgandvgfinevgtremorsvgofvgthevghands.
Avgclientvghasvgavgserumvgpotassiumvglevelvgofvg3vgmEq/
L.vgWhichvgfindingsvgshouldvgthevgpracticalvgnursevgreportvgtovgthevgchargevgnurse?vg
(Selectvgallvgthatvgapply.)
A.vgMusclevgcramps
B.vgDiarrhea
C.vgAlteredvgbloodvgglucosevglevel
D.vgIncreasedvgenergy
E.vgAbnormalvgheartvgrhythms
F.vgIncreasedvganxietyvg-vganswer--A.vgMusclevgcramps
E.vgAbnormalvgheartvgrhythms
Rationale:vgAvgnormalvgpotassiumvglevelvgrangesvgfromvg3.5vgtovg5vgmEq/Lvg(mmol/
L).vgSignsvgandvgsymptomsvgofvglowvgpotassiumvgincludevgmusclevgcrampsvgandvgdysrhythmias.
Avgclientvgdiagnosedvgwithvgdiabetesvgmellitusvgcomplainsvgofvgvomitingvgandvgfeelingvgconfusedvgtovgthevgpracticalvgnurse.
vgWhichvgofvgthevgfollowingvgsymptomsvgarevgpossiblevgsignsvgofvgdiabeticvgketoacidosisvg(DKA)?
vg(Selectvgallvgthatvgapply.)
A.vgFruityvgbreathvgodor
B.vgRapid,vgweakvgpulse
C.vgCold,vgclammyvgskin
D.vgExtremevgthirst
E.vgUrinaryvgfrequency
F.vgProtrudingvgeyeballsvg-vganswer--A.vgFruityvgbreathvgodor
B.vgRapid,vgweakvgpulse
D.vgExtremevgthirst
E.vgUrinaryvgfrequency
Rationale:vgDiabeticvgketoacidosisvgisvgcausedvgbyvgavgprofoundvgdeficiencyvgofvginsulin.vgSomevgcommonvgcharacteristic
svgincludevgavgsweet,vgfruityvgbreathvgodor;vgavgrapidvgweakvgpulse;vgextremevgthirst;vgurinaryvgfrequency;vgandvgsunken-
appearingvgeyeballs.
Whatvgisvgthevgdepthvgofvgthevgcompressionvgthevgpracticalvgnursevg(PN)vgshouldvgdovgwhenvgperformingvgthevgmanualvgch
estvgcompressionsvgduringvgcardiopulmonaryvgresuscitationvg(CPR)vgonvganvgadultvgclient?
A.vg0.5vginchvg(1.27vgcm)vgtovg1vginchvg(2.54vgcm)
B.vg1.5vginchvg(3.8vgcm)vgtovg2vginchesvg(5vgcm)
C.vg2vginchesvg(5vgcm)vgtovg2.4vginchesvg(6vgcm)
1vg/
vg11
, HESI Comprehensive Exit Exam 1 (And Rati
vg vg vg vg vg vg
onale)
D.vg2.5vginchesvg(6.4vgcm)vgtovg3vginchesvg(7.6vgcm)vg-vganswer--C.vg2vginchesvg(5vgcm)vgtovg2.4vginchesvg(6vgcm
Rationale:vgAccordingvgtovgthevgAmericanvgHeartvgAssociationvg2015vgguidelines,vgthevgdepthvgofvgcompressionsvgonvganv
gadultvgduringvgCPRvgshouldvgbevgatvgleastvg2vginchesvg(5vgcm)vgtovg2.4vginchesvg(6vgcm).
Avgclientvgdiagnosedvgwithvgavgskullvghematomavgandvgfracturedvg(L)vgclaviclevgstatusvgpostvgavgsixvgfootvgfallvgfromvgavgladd
ervgisvgadmittedvgtovgthevgunit.vgWhichvgsignvgshouldvgthevgpracticalvgnursevg(PN)vgreportvgimmediately?
A.vgSpontaneouslyvgopensvgeyes
.B.vgObeysvgcommandsvginvgmovementvgandvggrip.
C.vgAnswersvgquestions,vgbutvgisvgconfused.
D.vgHasvgabnormalvgflexionvgorvgextensionvgofvg(L)vgarm.vg-vganswer--C.vgAnswersvgquestions,vgbutvgisvgconfused.
Rationale:vg"Thevgquestionvgaskvgwhichvgshouldvgbevgreportvgimmediately?"vgAnvgabnormalvgchangevginvgconditionvgrelate
dvgtovgDx.vgConfusionvgstatusvgpostvgavgheadvginjuryvgisvgusuallyvgthevgfirstvgsignvgofvgincreasedvgintracranialvgpressure.
Avgclientvgdiagnosedvgwithvgduodenalvgulcersvgisvgadmittedvgtovgthevghospital.vgThevgclientvgwasvgadministeredvgranitidinevg
hydrochloridevg150vgmgvgPOvgatvgbedtime.vgWhichvgfindingvgwouldvgindicatevgavgtherapeuticvgresponsevgofvgthevgmedicati
on?
A.vgGastricvgsecretionsvgpHvglevelvgbelowvg3.
B.vgHemoccultvgtestingvgisvgpositivevgonvgtwovgdifferentvgoccasions.
C.vgNovgdifficultyvgfallingvgasleepvgreported.
D.vgNovgcomplaintsvgofvgabdominalvgpainvgorvgheartburnvgverbalized.vg-vganswer--
D.vgNovgcomplaintsvgofvgabdominalvgpainvgorvgheartburnvgverbalized.
Rationale:vgItvgisvgaskingvgtovgindicatevgavgtherapeuticvgresponsevgofvgthevgmedication.vgsovgknowvgyourvgmedications.
Lackvgofvgabdominalvgpainvgwithinvg4vghoursvgaftervgmealsvgindicatesvgdecreasedvgduodenalvgirritation,vgavgpositivevgoutco
mevginvgthevgtreatmentvgofvgduodenalvgulcer.
Avgclientvgdiagnosedvgwithvgdiabetesvgcomplainsvgtovgthevgpracticalvgnursevgofvgdecreasedvgtactilevgsensationvginvgtheirvgfe
etvgandvgfeelingsvglikevgtheirvgfeetvgarevgonvgfirevgsometimes.vgWhichvgabnormalvglaboratoryvgfindingvgshouldvgthevgpractical
vgnursevg(PN)vgidentifyvgthatvgindicatesvgthatvgavgclientvgwithvgdiabetesvgneedsvgfurthervgevaluationvgforvgdiabeticvgnephropa
thy?
A.vgHypokalemia
B.vgMicroalbuminuria
C.vgElevatedvgserumvglipids
D.vgKetonuriavg-vganswer--
Rationale:vgMicroalbuminuriavgisvgthevgearliestvgsignvgofvgdiabeticvgnephropathyvgandvgindicatesvgthevgneedvgforvgfollow-
upvgevaluation.
Avgclientvgdiagnosedvgwithvglymphomavgisvgreceivingvgchemotherapy.vgThevgclient'svghemoglobinvgisvgcurrentlyvg6vgg/
dL.vgThevgpracticalvgnursevg(PN)vgassignsvganvgunlicensedvgassistivevgpersonnelvg(UAP)vgtovgprovidevgpersonalvghygienev
gforvgthisvgclient.vgWhatvginstructionvgshouldvgthevgPNvgprovidevgtovgthevgUAP?
A.vgReportvganyvgsignsvgofvgnauseavgorvgvomitingvgimmediately.
B.vgThevgclientvgwillvgbevgweakvgandvgunsteadyvgandvgtirevgeasily.
C.vgWatchvgcarefullyvgforvganyvgsignsvgofvgbleeding.
D.vgThevgclient'svgskinvgwillvgbevgfragilevgandvgbruisevgeasily.vg-vganswer--
B.vgThevgclientvgwillvgbevgweakvgandvgunsteadyvgandvgtirevgeasily.
2vg/
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