2025/2026 HESI PN EXIT V3/
HESI EXIT /VERSION 3/EXIT
EXAMS/ HESI COMPLETE TEST
BANK
• 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.
• The nurse is preparing a 4-day-old I infant with a serum bilirubin level of
19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching
the parents about home phototherapy, which instruction should the nurse
include in the discharge teaching plan?
• Reposition the infant every 2 hours.
• Perform diaper changes under the light.
, • Feed the infant every 4 hours.
• Cover with a receiving blanket.
• Rational: An infant, who is receiving phototherapy for
hyperbilirubinemia, should be repositioned every two hours. The
position changes ensure that the phototherapy lights reach all of the
body surface areas. Bathing, feedings, and diaper changes are ways
for the parents to bond with the infant, and can occur away from the
treatment. Feedings need to occur more frequently than every 4 hours
to prevent dehydration. The infant should wear only a diaper so that
the skin is exposed to the phototherapy.
• A 13 years-old client with non-union of a comminuted fracture of the tibia is
admitted with osteomyelitis. The healthcare provider collects home aspirate
specimens for culture and sensitivity and applies a cast to the adolescent’s
lower leg. What action should the nurse implement next?
• Administer antiemetic agents
• Bivalve the cast for distal compromise
• Provide high- calorie, high-protein diet
• Begin parenteral antibiotic therapy
• Rationale: The standard of treatment for osteomyelitis is antibiotic
therapy and immobilization. After bond and blood aspirate specimens
are obtained for culture and sensitivity, the nurse should initiate
parenteral antibiotics as prescribed.
• The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation?
• Recommend weigh bearing physical activity
• A client with a history of chronic pain requests a nonopioid analgesic. The
, client is alert but has difficulty describing the exact nature and location of the
pain to the nurse. What action should the nurse implement next?
• Administer the analgesic as requested
• A male fclient freceives fa fthrombolytic fmedication ffollowing fa fmyocardial
infarction. fWhenfthe fclient fhas fa fbowel fmovement, fwhat faction fshould fthe
f
nurse fimplement?
f
• Send fstool fsample fto fthe flab ffor fa fguaiac ftest
• Observe fstool ffor fa fday-colored fappearance.
• Obtain fspecimen ffor fculture fand fsensitivity fanalysis
• Asses ffor ffatty fyellow fstreaks fin fthe fclient’s fstool.
, • Rationale: fThrombolytic fdrugs fincrease fthe ftendency ffor fbleeding.
So fguaiac f(occult fblood ftest) ftest fof fthe fstool fshould fbe fevaluated
f
to fdetect fbleeding fin fthefintestinal ftract.
f
• The fmother fof fa fchild fwith fcerebral fpalsy f(CP) fask fthe fnurse fif fher fchild’s
fimpaired fmovements fwill fworsen fas fthe fchild fgrows. fWhich fresponse
fprovides fthe fbest fexplanation?
• Brain fdamage fwith fCP fis fnot fprogressive fbut fdoes fhave fa fvariable
f course
• During fshift freport, fthe fcentral felectrocardiogram f(EKG) fmonitoring fsystem
falarms. fWhichfclient falarm fshould fthe fnurse finvestigate ffirst?
• Respiratory fapnea fof f30 fseconds
• In fearly fseptic fshock fstates, fwhat fis fthe fprimary fcause fof fhypotension?
• Peripheral fvasoconstriction
• Peripheral fvasodilation
• Cardiac ffailure
• A fvagal fresponse
• Rationale: fToxins freleased fby fbacteria fin fseptic fshock fcreate fmassive
fperipheralfvasodilation fand fincrease fmicrovascular fpermeability fat fthe fsite
fof fthe fbacterialfinvasion
• When fplanning fcare ffor fa fclient fwith facute fpancreatitis, fwhich fnursing
fintervention fhasfthe fhighest fpriority?
HESI EXIT /VERSION 3/EXIT
EXAMS/ HESI COMPLETE TEST
BANK
• 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.
• The nurse is preparing a 4-day-old I infant with a serum bilirubin level of
19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching
the parents about home phototherapy, which instruction should the nurse
include in the discharge teaching plan?
• Reposition the infant every 2 hours.
• Perform diaper changes under the light.
, • Feed the infant every 4 hours.
• Cover with a receiving blanket.
• Rational: An infant, who is receiving phototherapy for
hyperbilirubinemia, should be repositioned every two hours. The
position changes ensure that the phototherapy lights reach all of the
body surface areas. Bathing, feedings, and diaper changes are ways
for the parents to bond with the infant, and can occur away from the
treatment. Feedings need to occur more frequently than every 4 hours
to prevent dehydration. The infant should wear only a diaper so that
the skin is exposed to the phototherapy.
• A 13 years-old client with non-union of a comminuted fracture of the tibia is
admitted with osteomyelitis. The healthcare provider collects home aspirate
specimens for culture and sensitivity and applies a cast to the adolescent’s
lower leg. What action should the nurse implement next?
• Administer antiemetic agents
• Bivalve the cast for distal compromise
• Provide high- calorie, high-protein diet
• Begin parenteral antibiotic therapy
• Rationale: The standard of treatment for osteomyelitis is antibiotic
therapy and immobilization. After bond and blood aspirate specimens
are obtained for culture and sensitivity, the nurse should initiate
parenteral antibiotics as prescribed.
• The nurse is preparing a community education program on osteoporosis. Which
instruction is helpful in preventing bone loss and promoting bone formation?
• Recommend weigh bearing physical activity
• A client with a history of chronic pain requests a nonopioid analgesic. The
, client is alert but has difficulty describing the exact nature and location of the
pain to the nurse. What action should the nurse implement next?
• Administer the analgesic as requested
• A male fclient freceives fa fthrombolytic fmedication ffollowing fa fmyocardial
infarction. fWhenfthe fclient fhas fa fbowel fmovement, fwhat faction fshould fthe
f
nurse fimplement?
f
• Send fstool fsample fto fthe flab ffor fa fguaiac ftest
• Observe fstool ffor fa fday-colored fappearance.
• Obtain fspecimen ffor fculture fand fsensitivity fanalysis
• Asses ffor ffatty fyellow fstreaks fin fthe fclient’s fstool.
, • Rationale: fThrombolytic fdrugs fincrease fthe ftendency ffor fbleeding.
So fguaiac f(occult fblood ftest) ftest fof fthe fstool fshould fbe fevaluated
f
to fdetect fbleeding fin fthefintestinal ftract.
f
• The fmother fof fa fchild fwith fcerebral fpalsy f(CP) fask fthe fnurse fif fher fchild’s
fimpaired fmovements fwill fworsen fas fthe fchild fgrows. fWhich fresponse
fprovides fthe fbest fexplanation?
• Brain fdamage fwith fCP fis fnot fprogressive fbut fdoes fhave fa fvariable
f course
• During fshift freport, fthe fcentral felectrocardiogram f(EKG) fmonitoring fsystem
falarms. fWhichfclient falarm fshould fthe fnurse finvestigate ffirst?
• Respiratory fapnea fof f30 fseconds
• In fearly fseptic fshock fstates, fwhat fis fthe fprimary fcause fof fhypotension?
• Peripheral fvasoconstriction
• Peripheral fvasodilation
• Cardiac ffailure
• A fvagal fresponse
• Rationale: fToxins freleased fby fbacteria fin fseptic fshock fcreate fmassive
fperipheralfvasodilation fand fincrease fmicrovascular fpermeability fat fthe fsite
fof fthe fbacterialfinvasion
• When fplanning fcare ffor fa fclient fwith facute fpancreatitis, fwhich fnursing
fintervention fhasfthe fhighest fpriority?
