HESI PN EXIT EXAM V3 LATEST VERSION
2025-2026 ALL 110 QUESTIONS AND VERIFIED
ANSWERS PLUS RATIONALES/PN HESI EXIT
EXAM V3
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.
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
• 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 man shares with the nurse that he is having difficulty making decision about
terminating life support for his wife. What is the best initial action by the nurse?
• Provide an opportunity for him to clarify his values related to the decision
• Encourage him to share memories about his life with his wife and family
• Advise him to seek several opinions before making decision
• Offer to contact the hospital chaplain or social worker to offer support.
• Rationale: When a client is faced with a decisional conflict, the nurse should first
provide opportunities for the client to clarify values important in the decision. The
rest may also be beneficial once the client as clarified the values that are
important to him in the decision-making process.
10. A client is abeing adischarged ahome aafter abeing atreated afor aheart afailure a(HF). aWhat
ainstruction ashould athe anurse ainclude ain athis aclient’s adischarge ateaching aplan?
• Weigh aevery amorning
• Eat aa ahigh aprotein adiet
• Perform arange aof amotion aexercises
• Limit afluid aintake ato a1,500 aml adaily
11. A awoman ajust alearned athat ashe awas ainfected awith aHeliobacter apylori. aBased aon athis
afinding, awhich ahealth apromotion apractice ashould athe anurse asuggest?
• Encourage ascreening afor aa apeptic aulcer
12. A aclient awho arecently aunderwear aa atracheostomy ais abeing aprepared afor adischarge ato
ahome. aWhich ainstructions ais amost aimportant afor athe anurse ato ainclude ain athe
adischarge aplan?
• Teach atracheal asuctioning atechniques
13. A achild awith aheart afailure ais areceiving athe adiuretic afurosemide a(Lasix) aand ahas
aserum apotassium alevel a3.0 amEq/L. aWhich aassessment ais amost aimportant afor athe
anurse ato aobtain?
• Cardiac arhythm aand aheart arate.
• Daily aintake aof afoods arich ain apotassium.
• Hourly aurinary aoutput
• Thirst aad askin aturgor.
14. The anurse anote aa adepressed afemale aclient ahas abeen amore awithdrawn aand anon-
communicative aduring athe apast atwo aweeks. aWhich aintervention ais amost aimportant ato
ainclude ain athe aupdated aplan aof acare afor athis aclient?
, • Encourage athe aclient’s afamily ato avisit amore aoften
• Schedule aa adaily aconference awith athe asocial aworker
• Encourage athe aclient ato aparticipate ain agroup aactivities
• Engage athe aclient ain aa anon-threatening aconversation.
• Rationale: aConsistent aattempts ato adraw athe aclient ainto aconversations awhich
afocus aon anon-threatening asubjects acan abe aan aeffective ameans aof aeliciting aa
aresponse,
thereby adecreasing aisolation abehaviors. aThere ais anot asufficient adata ato asupport
athe aeffectiveness aof aA aas aan aintervention afor athis aclient. aAlthough aB amay abe
aindicated, anursing ainterventions acan aalso abe aused ato atreat athis aclient. aC ais
atoo athreatening ato athis aclient.
15. A aclient awith arheumatoid aarthritis a(RA) astarts aa anew aprescription aof aetanercept
a(Enbrel) asubcutaneously aonce aweekly. aThe anurse ashould aemphasize athe
aimportance aof areporting aproblem ato athe ahealthcare aprovider?
• Headache
• Joint astiffness
• Persistent afever
• Increase ahunger aand athirst
• Rationale: aEnbrel adecrease aimmune aand ainflammatory aresponses, aincreasing
athe aclient’s arisk aof aserious ainfection, aso athe aclient ashould abe ainstructed ato
areport aa apersistent afever, aor aother asigns aof ainfection ato athe ahealthcare
aprovider.
16. The anurse ais aassessing aan aolder aadult awith atype a2 adiabetes amellitus. aWhich aassessment
afinding aindicates athat athe aclient aunderstands along- aterm acontrol aof adiabetes?
• The afating ablood asugar awas a120 amg/dl athis amorning.
• Urine aketones ahave abeen anegative afor athe apast a6 amonths
• The ahemoglobin aA1C awas a6.5g/100 aml alast aweek
• No adiabetic aketoacidosis ahas aoccurred ain a6 amonths.
• Rationale: aA ahemoglobin aA1C alevel areflects ahe aaverage ablood asugar athe
aclient ahad aover athe aprevious a2 ato a3 amonth, aand alevel aof a6.5 ag/100 aml
asuggest athat athe aclient
understand along-term adiabetes acontrol. aNormal avalue ain aa adiabetic apatient ais
aup ato
6.5 ag/100 aml.
17. An aolder amale aclient ais aadmitted awith athe amedical adiagnosis aof apossible acerebral
avascular aaccident a(CVA). aHe ahas afacial aparalysis aand acannot amove ahis aleft aside.
aWhen aentering athe aroom, athe anurse afinds athe aclient’s awife atearful aand atrying
aunsuccessfully ato agive ahim aa adrink aof awater. aWhat aaction ashould athe anurse atake?
2025-2026 ALL 110 QUESTIONS AND VERIFIED
ANSWERS PLUS RATIONALES/PN HESI EXIT
EXAM V3
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.
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
• 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 man shares with the nurse that he is having difficulty making decision about
terminating life support for his wife. What is the best initial action by the nurse?
• Provide an opportunity for him to clarify his values related to the decision
• Encourage him to share memories about his life with his wife and family
• Advise him to seek several opinions before making decision
• Offer to contact the hospital chaplain or social worker to offer support.
• Rationale: When a client is faced with a decisional conflict, the nurse should first
provide opportunities for the client to clarify values important in the decision. The
rest may also be beneficial once the client as clarified the values that are
important to him in the decision-making process.
10. A client is abeing adischarged ahome aafter abeing atreated afor aheart afailure a(HF). aWhat
ainstruction ashould athe anurse ainclude ain athis aclient’s adischarge ateaching aplan?
• Weigh aevery amorning
• Eat aa ahigh aprotein adiet
• Perform arange aof amotion aexercises
• Limit afluid aintake ato a1,500 aml adaily
11. A awoman ajust alearned athat ashe awas ainfected awith aHeliobacter apylori. aBased aon athis
afinding, awhich ahealth apromotion apractice ashould athe anurse asuggest?
• Encourage ascreening afor aa apeptic aulcer
12. A aclient awho arecently aunderwear aa atracheostomy ais abeing aprepared afor adischarge ato
ahome. aWhich ainstructions ais amost aimportant afor athe anurse ato ainclude ain athe
adischarge aplan?
• Teach atracheal asuctioning atechniques
13. A achild awith aheart afailure ais areceiving athe adiuretic afurosemide a(Lasix) aand ahas
aserum apotassium alevel a3.0 amEq/L. aWhich aassessment ais amost aimportant afor athe
anurse ato aobtain?
• Cardiac arhythm aand aheart arate.
• Daily aintake aof afoods arich ain apotassium.
• Hourly aurinary aoutput
• Thirst aad askin aturgor.
14. The anurse anote aa adepressed afemale aclient ahas abeen amore awithdrawn aand anon-
communicative aduring athe apast atwo aweeks. aWhich aintervention ais amost aimportant ato
ainclude ain athe aupdated aplan aof acare afor athis aclient?
, • Encourage athe aclient’s afamily ato avisit amore aoften
• Schedule aa adaily aconference awith athe asocial aworker
• Encourage athe aclient ato aparticipate ain agroup aactivities
• Engage athe aclient ain aa anon-threatening aconversation.
• Rationale: aConsistent aattempts ato adraw athe aclient ainto aconversations awhich
afocus aon anon-threatening asubjects acan abe aan aeffective ameans aof aeliciting aa
aresponse,
thereby adecreasing aisolation abehaviors. aThere ais anot asufficient adata ato asupport
athe aeffectiveness aof aA aas aan aintervention afor athis aclient. aAlthough aB amay abe
aindicated, anursing ainterventions acan aalso abe aused ato atreat athis aclient. aC ais
atoo athreatening ato athis aclient.
15. A aclient awith arheumatoid aarthritis a(RA) astarts aa anew aprescription aof aetanercept
a(Enbrel) asubcutaneously aonce aweekly. aThe anurse ashould aemphasize athe
aimportance aof areporting aproblem ato athe ahealthcare aprovider?
• Headache
• Joint astiffness
• Persistent afever
• Increase ahunger aand athirst
• Rationale: aEnbrel adecrease aimmune aand ainflammatory aresponses, aincreasing
athe aclient’s arisk aof aserious ainfection, aso athe aclient ashould abe ainstructed ato
areport aa apersistent afever, aor aother asigns aof ainfection ato athe ahealthcare
aprovider.
16. The anurse ais aassessing aan aolder aadult awith atype a2 adiabetes amellitus. aWhich aassessment
afinding aindicates athat athe aclient aunderstands along- aterm acontrol aof adiabetes?
• The afating ablood asugar awas a120 amg/dl athis amorning.
• Urine aketones ahave abeen anegative afor athe apast a6 amonths
• The ahemoglobin aA1C awas a6.5g/100 aml alast aweek
• No adiabetic aketoacidosis ahas aoccurred ain a6 amonths.
• Rationale: aA ahemoglobin aA1C alevel areflects ahe aaverage ablood asugar athe
aclient ahad aover athe aprevious a2 ato a3 amonth, aand alevel aof a6.5 ag/100 aml
asuggest athat athe aclient
understand along-term adiabetes acontrol. aNormal avalue ain aa adiabetic apatient ais
aup ato
6.5 ag/100 aml.
17. An aolder amale aclient ais aadmitted awith athe amedical adiagnosis aof apossible acerebral
avascular aaccident a(CVA). aHe ahas afacial aparalysis aand acannot amove ahis aleft aside.
aWhen aentering athe aroom, athe anurse afinds athe aclient’s awife atearful aand atrying
aunsuccessfully ato agive ahim aa adrink aof awater. aWhat aaction ashould athe anurse atake?
