HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWER(S) UPDATED WITH THE CORRECT ANSWERS HIGHLIGHTED.

• 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 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