HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWER(S)

HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWER(S) • 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. • 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 • 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 • 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 • 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. • 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. • 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 • 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