HESI PN COMPREHENSIVE
EXIT EXAM 2023\2024
1. The nurse is administering pain medication for several patients. Which patient
does the nurse administer
... [Show More] medication to first?
a. The patient who needs to be premedicated before walking
b. The patient who has a PCA running that
needs the syringe replaced The patient who
needs to take a scheduled dose of
maintenance pain
c. medication
The patient who is experiencing 8/10 pain and has an immediate order
for pain medication
ANS: D
Immediate (STAT) medications need to be given as soon as possible. In
addition, this patient is the priority because of the report of severe pain. The
other patients need pain medication, but their situations are not as high a
priority as that of the patient with the STAT medication order.
2. The nurse is assessing a patient for opioid tolerance. Which finding supports the
nurse’s assessment?
a. The patient needed a substantial dose of naloxone (Narcan).
b. The patient needs increasingly higher doses
of opioid to control pain. The patient no
longer experiences sedation from the usual
dose of
c. opioid.
The patient asks for pain medication close to the time it is due around
the clock.
ANS: B
Opioid tolerance occurs when a patient needs higher doses of an opioid to control
pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects
of opioid overdose. Taking pain medications regularly around the clock is an
effective way to control pain. The pain medication for this patient is most likely
effectively managing the patient’s pain because the patient is not asking for the
medication before it is due. A patient no longer experiencing a side effect
(sedation) of an opioid does not indicate opioid tolerance.
29.A nurse is caring for a patient with rheumatoid arthritis who is now going to
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be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain.
Which part of the patient’s social history is the
nurse most concerned about?
a. Patient drinks 1 to 2 glasses of wine every night.
b. Patient smokes 2 packs of cigarettes a day.
c. Patient occasionally uses marijuana.
d. Patient takes antianxiety medications.
ANS: A
The major adverse effect of acetaminophen is hepatotoxicity (liver toxicity).
Because both alcohol and acetaminophen are metabolized by the liver, when taken
together, they can cause liver damage. Smoking cigarettes and smoking marijuana
are not healthy behaviors, but their effects on health are not affected by
acetaminophen. Antianxiety medications can be taken with acetaminophen.
30. The nurse is caring for a patient who suddenly experiences chest pain. What is
the nurse’s first priority?
a. Call the rapid response team.
b. Start an intravenous (IV) line.
c. Administer pain-relief medications.
d. Ask the patient to rate and describe the pain.
ANS: D
The nurse’s ability to establish a nursing diagnosis, plan and implement care, and
evaluate the effectiveness of care depends on an accurate and timely assessment.
The other responses are all interventions; the nurse cannot know which
intervention is appropriate until the nurse completes the assessment.
31. The nurse is caring for a group of patients. Which task may the nurse
delegate to the nursing assistive personnel (NAP)?
a. Administer a back massage to a patient with pain.
b. Assessment of pain for a patient reporting abdominal pain.
c. Administer patient-controlled analgesia for a postoperative patient.
d. Assessment of vital signs in a patient receiving epidural analgesia.
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ANS: A
A massage may be delegated to an NAP. Pain assessment is a nursing function and
cannot be delegated to an NAP. Administration of patient-controlled analgesia
(PCA) cannot be delegated to an NAP. Assessment of vital signs is a licensed
nursing function; the NAP can take vital signs for a patient receiving epidural
analgesia.
32.A nurse is caring for a patient with chronic pain from arthritis. Which action is
best for the nurse to take?
a. Give pain medications around the clock.
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pain scale.
Administer pain medication only when nonpharmacological measures
have failed.
ANS: A
When a patient with arthritis has chronic pain, the best way to manage pain is to
take medication regularly throughout the day to maintain constant pain relief.
“Before any activity” is nonspecific, and the medication may not have time to
work before activity. If the patient waits until having pain (7/10) to take the
medication, pain relief takes longer. Nonpharmacological measures are used in
conjunction with medications unless requested otherwise by the patient.
33.A nurse is caring for a patient who fell on the ice and has connective tissue
damage in the wrist and hand. The patient describes the pain as throbbing. Which
type of pain does the nurse document in this patient’s medical record?
a. Visceral pain
b. Somatic pain
c. Centrally generated pain
d. Peripherally generated pain
ANS: B
Somatic pain comes from bone, joint, connective tissue, or muscle. Visceral pain
arises from the visceral (internal) organs such as the GI tract and pancreas.
Peripherally generated pain in the peripheral nerves can be caused by
polyneuropathies or mononeuropathies. Centrally generated pain results from
injury to the central or peripheral nervous system, causing deafferentation or
sympathetically maintained pain.
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34.The nurse is caring for an infant in the intensive care unit. Which information
should the nurse consider when planning care for this patient?
a. Infants cannot be assessed for pain.
b. Infants respond behaviorally and
physiologically to painful stimuli. Infants
cannot tolerate analgesics owing to an
underdeveloped
c. metabolism.
Infants have a decreased sensitivity to pain when compared with older
children.
ANS: B
Infants cannot verbally express their pain, but they do express pain with
behavioral cues (facial expressions, crying) and physiological indicators (changes
in vital signs). Infants can tolerate analgesics, but proper dosing and close
monitoring are essential. Infants and older children have the same sensitivity to
pain. Pain can be assessed even though the neonate cannot verbalize; the nurse
can observe behavioral clues. Nurses use behavioral cues and physiological
responses to assess pain in infants.
MULTIPLE RESPONSE
1.The nurse is administering ibuprofen (Advil) to an older patient. Which
assessment data causes the nurse to hold the medication? (Select all that apply.)
a. Patient states allergy to aspirin.
b. Patient states joint pain is 2/10 and intermittent.
c. Patient reports past medical history of gastric ulcer.
d. Patient reports last bowel movement was 4 days ago.
Patient experiences respiratory depression after administration of an
e. opioid medication. [Show Less]