EXIT HESI PN 2027 SETS ANSWERS AND QUESTIONS
SET A+
✔✔The client with which fasting plasma glucose level needs the most immediate
intervention by the nurse?
A.50 mg/dL
B.80 mg/dL
C.110 mg/dL
D.140 mg/dL - ✔✔A
The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a
low level, such as 50 mg/dL (A), requires the most immediate intervention to prevent
loss of consciousness. Normal (B) and slightly elevated levels, such as 110 or 140
mg/dL (C and D), do not require immediate intervention.
✔✔A very busy hospital unit has had several discharges and the census is unusually
low. What is the best way for the charge nurse to use the time of the nursing staff?
A.Encourage staff to participate in online in-service education.
B.Assign staff to make sure that all equipment is thoroughly cleaned.
C.Ask which staff members would like to go home for the remainder of the day.
D.Notify the supervisor that the staff needs additional assignments. - ✔✔A
Online educational programs are available around the clock, so staff can engage in
continuing education programs when the opportunity arises, such as during periods of
low census (A). (B) is not the responsibility of the nursing staff. (C) is not the best use of
staff and does not use the extra time provided by the low census. The charge nurse
should use the time to improve the unit, and requesting additional assignments is not
necessary (D)
✔✔When the administration at a large urban medical center decides to establish a unit
to care for clients with infectious diseases, such as severe acute respiratory syndrome
(SARS) and the avian flu, several employees express fear related to caring for these
clients. When choosing staff to work on this unit, which action is best for the nurse-
manager to take?
, A.Make it clear that no one who is afraid to care for clients with rare disorders will be
permitted to work on the unit.
B.Conduct an education program about infectious diseases and then assess the staff's
willingness to work with these clients.
C.Introduce the staff to the family of a client who has been treated for SARS and ask
the staff to share their fears with this family.
D.Assign staff based on the needs of the unit, providing peer counseling for those staff
members who express fear. - ✔✔B
Fear is often related to a lack of knowledge and an education program about the
relevant disorders would be appropriate, but after the education program, the nursing
staff should be reassessed regarding their willingness to work with these clients (B). (A)
is too authoritarian and does not permit education to play a role in reducing fears. (C) is
likely to be intrusive to the family member. Arbitrary staffing (D) without education does
not reduce staff fears, even with the provision of peer counseling.
✔✔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. -
✔✔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
C.Serum potassium level is 2.5 mEq/L
D.Apical pulse is 68/min - ✔✔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 - ✔✔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.
✔✔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. -
✔✔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 - ✔✔A
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.
SET A+
✔✔The client with which fasting plasma glucose level needs the most immediate
intervention by the nurse?
A.50 mg/dL
B.80 mg/dL
C.110 mg/dL
D.140 mg/dL - ✔✔A
The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a
low level, such as 50 mg/dL (A), requires the most immediate intervention to prevent
loss of consciousness. Normal (B) and slightly elevated levels, such as 110 or 140
mg/dL (C and D), do not require immediate intervention.
✔✔A very busy hospital unit has had several discharges and the census is unusually
low. What is the best way for the charge nurse to use the time of the nursing staff?
A.Encourage staff to participate in online in-service education.
B.Assign staff to make sure that all equipment is thoroughly cleaned.
C.Ask which staff members would like to go home for the remainder of the day.
D.Notify the supervisor that the staff needs additional assignments. - ✔✔A
Online educational programs are available around the clock, so staff can engage in
continuing education programs when the opportunity arises, such as during periods of
low census (A). (B) is not the responsibility of the nursing staff. (C) is not the best use of
staff and does not use the extra time provided by the low census. The charge nurse
should use the time to improve the unit, and requesting additional assignments is not
necessary (D)
✔✔When the administration at a large urban medical center decides to establish a unit
to care for clients with infectious diseases, such as severe acute respiratory syndrome
(SARS) and the avian flu, several employees express fear related to caring for these
clients. When choosing staff to work on this unit, which action is best for the nurse-
manager to take?
, A.Make it clear that no one who is afraid to care for clients with rare disorders will be
permitted to work on the unit.
B.Conduct an education program about infectious diseases and then assess the staff's
willingness to work with these clients.
C.Introduce the staff to the family of a client who has been treated for SARS and ask
the staff to share their fears with this family.
D.Assign staff based on the needs of the unit, providing peer counseling for those staff
members who express fear. - ✔✔B
Fear is often related to a lack of knowledge and an education program about the
relevant disorders would be appropriate, but after the education program, the nursing
staff should be reassessed regarding their willingness to work with these clients (B). (A)
is too authoritarian and does not permit education to play a role in reducing fears. (C) is
likely to be intrusive to the family member. Arbitrary staffing (D) without education does
not reduce staff fears, even with the provision of peer counseling.
✔✔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. -
✔✔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
C.Serum potassium level is 2.5 mEq/L
D.Apical pulse is 68/min - ✔✔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 - ✔✔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.
✔✔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. -
✔✔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 - ✔✔A
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.
