HESI PN EXIT EXAM V3 110 QUESTIONS
AND ANSWER(S)
1. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to
the
... [Show More] 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 being discharged home after being treated for heart failure (HF). What instruction
should the nurse include in this client’s discharge teaching plan?
Weigh every morning
Eat a high protein diet
Perform range of motion exercises
Limit fluid intake to 1,500 ml daily
11. A woman just learned that she was infected with Heliobacter pylori. Based on this finding,
which health promotion practice should the nurse suggest?
Encourage screening for a peptic ulcer
12. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
13. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?
Cardiac rhythm and heart rate.
Daily intake of foods rich in potassium. Hourly urinary output
Thirst ad skin turgor.
14. The nurse note a depressed female client has been more withdrawn and non-communicative
during the past two weeks. Which intervention is most important to include in the updated
plan of care for this client?
Encourage the client’s family to visit more often
Schedule a daily conference with the social worker
Encourage the client to participate in group activities
Engage the client in a non-threatening conversation.
Rationale: Consistent attempts to draw the client into conversations which focus
on non-threatening subjects can be an effective means of eliciting a response,
thereby decreasing isolation behaviors. There is not sufficient data to support the
effectiveness of A as an intervention for this client. Although B may be indicated,
nursing interventions can also be used to treat this client. C is too threatening to
this client.
15. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)
subcutaneously once weekly. The nurse should emphasize the importance of reporting
problem to the healthcare provider?
Headache
Joint stiffness
Persistent fever
Increase hunger and thirst
Rationale: Enbrel decrease immune and inflammatory responses, increasing the
client’s risk of serious infection, so the client should be instructed to report a
persistent fever, or other signs of infection to the healthcare provider.
16. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding
indicates that the client understands long- term control of diabetes?
The fating blood sugar was 120 mg/dl this morning.
Urine ketones have been negative for the past 6 months
The hemoglobin A1C was 6.5g/100 ml last week
No diabetic ketoacidosis has occurred in 6 months.
Rationale: A hemoglobin A1C level reflects he average blood sugar the client had
over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the clientunderstand long-term diabetes control. Normal value in a diabetic patient is up to
6.5 g/100 ml.
17. An older male client is admitted with the medical diagnosis of possible cerebral vascular
accident (CVA). He has facial paralysis and cannot move his left side. When entering the
room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of
water. What action should the nurse take?
Ask the wife to stop and assess the client’s swallowing reflex
18. 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.
19. 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
20. 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
21. A male client receives a thrombolytic medication following a myocardial infarction. When
the client has a bowel movement, what action should the nurse implement?
Send stool sample to the lab for a guaiac test
Observe stool for a day-colored appearance.
Obtain specimen for culture and sensitivity analysis
Asses for fatty yellow streaks in the client’s stool. Rationale: Thrombolytic drugs increase the tendency for bleeding. So guaiac
(occult blood test) test of the stool should be evaluated to detect bleeding in the
intestinal tract.
22. The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired
movements will worsen as the child grows. Which response provides the best explanation?
Brain damage with CP is not progressive but does have a variable course
23. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which
client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds
24. In early septic shock states, what is the primary cause of hypotension?
Peripheral vasoconstriction
Peripheral vasodilation
Cardiac failure
A vagal response
Rationale: Toxins released by bacteria in septic shock create massive peripheral
vasodilation and increase microvascular permeability at the site of the bacterial
invasion.
25. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for
aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication
should the nurse bring to the healthcare provider’s attention?
Allopurinol (Zyloprim)
Aspirin, low dose
Furosemide (lasix)
Enalapril (vasote)
26. A male client’s laboratory results include a platelet count of 105,000/ mm3 Based on this
finding the nurse should include which action in the client’s plan of care?
Cluster care to conserve energy
Initiate contact isolation
Encourage him to use an electric razor
Asses him for adventitious lung sounds Rationale: This client is at risk for bleeding based on his platelet count (normal
150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for
shaving, should be encouraged to reduce the risk of bleeding.
27. A client is admitted to the hospital after experiencing a brain attack, commonly referred to as
a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech
therapy if the client exhibits which finding?
Abnormal responses for cranial nerves I and II
Persistent coughing while drinking
Unilateral facial drooping
Inappropriate or exaggerated mood swings
28. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the
client’s medical record. Based on date contained in the record, what action should the nurse
take before assisting the client with ambulation:
Remove sequential compression devices.
Apply PRN oxygen per nasal cannula.
Administer a PRN dose of an antipyretic.
Reinforce the surgical wound dressing.
Rationale: Sequential compression devices should be removed prior to ambulation
and there is no indication that this action is contraindicated. The client’s oxygen
saturation levels have been within normal limits for the previous four hours, so
supplemental oxygen is not warranted.
29. Which assessment finding for a client who is experiencing pontine myelinolysis should the
nurse report to the healthcare provider?
Sudden dysphagia
Blurred visual field
Gradual weakness
Profuse diarrhea
30. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after
receiving chemotherapy. The client has saline lock and is sleeping quietly without any
restlessness. The nurse caring for the client is not certified in chemotherapy administration.
What action should the nurse take?
Ask a chemotherapy-certified nurse to administer the Zofran
Administer the Zofran after flushing the saline lock with saline Hold the scheduled dose of Zofran until the client awakens
Awaken the client to assess the need for administration of the Zofran.
Rationale: Zofran is an antiemetic administered before and after chemotherapy to
prevent vomiting. The nurse should administer the antiemetic using the accepter
technique for IV administration via saline lock. Zofran is not a chemotherapy drug
and does not need to be administered by a chemotherapy- certified nurse.
31. When providing diet teaching for a client with cholecystitis, which types of food choices the
nurse recommend to the client?
High protein
Low fat
Low sodium
High carbohydrate.
Rationale: A client with cholecystitis is at risk of gall stones that can be move into
the biliary tract and cause pain or obstruction. Reducing dietary fat decrease
stimulation of the gall bladder, so bile can be expelled, along with possible stones,
into the biliary tract and small intestine.
32. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and
ascites. Which assessment finding warrants immediate intervention by the nurse?
Jaundice skin tone
Muffled heart sounds
Pitting peripheral edema
Bilateral scleral edema
Rationale: Muffled heart sounds may indicative fluid build-up in the pericardium
and is life- threatening. The other one are signs of end stage liver disease related
to alcoholism but are not immediately life- threatening.
33. When entering a client’s room, the nurse discovers that the client is unresponsive and
pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take
next?
Prepare to administer atropine 0.4 mg IVP
Gather emergency tracheostomy equipment
Prepare to administer lidocaine at 100 mg IVP
Place cardiac monitor leads on the client’s chest. Rationale: Before further interventions can be done, the client’s heart rhythm must
be determined. This can be done by connecting the client to the monitor. A or C
are not a first line drug given for any of the life threatening, pulses dysrhythmias
34. A client with a history of dementia has become increasingly confused at night and is picking
at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The
abdominal dressing is no longer occlusive, and the IV insertion site is pink. What
intervention should the nurse implement?
Replace the IV site with a smaller gauge.
Redress the abdominal incision
Leave the lights on in the room at night.
Apply soft bilateral wrist restraints.
Rationale: The abdominal incision should be redressed using aseptic-techniques.
The IV site should be assessed to ensure that it has not been dislodged and a
dressing reapplied, if need it. Leaving the light on at night may interfere with the
client’s sleep and increase confusion. Restraints are not indicated and should only
be used as a last resort to keep client from self-harm.
35. An adult male client is admitted to the emergency room following an automobile collision in
which he sustained a head injury. What assessment data would provide the earliest that the
client is experiencing increased intracranial pressure (ICP)?
Lethargy
Decorticate posturing
Fixed dilated pupil
Clear drainage from the ear.
Rationale: Lethargy is the earliest sign of ICP along with slowing of speech and
response to verbal commands. The most important indicator of increase ICP is the
client’s level or responsiveness or consciousness. B and C are very late signs of
ICP. [Show Less]