HESI RN EXIT V3 VERSION 3 EXAM WITH 110
QUESTIONS AND ANSWERS (UPDATE 2023 GRADED
A+ AND GUARANTEED/ HEALTHY SCI COH
315 HESI PN EXIT EXAM V3
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.
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of
19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching
the parents about home phototherapy, which instruction should the nurse
include in the discharge teaching plan?
• Reposition the infant every 2 hours.
• Perform diaper changes under the light.
• Feed the infant every 4 hours.
• Cover with a receiving blanket.
, • Rational: An infant, who is receiving phototherapy for
hyperbilirubinemia, should be repositioned every two hours. The
position changes ensure that the phototherapy lights reach all of the
body surface areas. Bathing, feedings, and diaper changes are ways
for the parents to bond with the infant, and can occur away from the
treatment. Feedings need to occur more frequently than every 4 hours
to prevent dehydration. The infant should wear only a diaper so that
the skin is exposed to the phototherapy.
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.
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
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
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.
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
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate first?
• Respiratory apnea of 30 seconds
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
When planning care for a client with acute pancreatitis, which nursing
intervention has the highest priority?
QUESTIONS AND ANSWERS (UPDATE 2023 GRADED
A+ AND GUARANTEED/ HEALTHY SCI COH
315 HESI PN EXIT EXAM V3
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.
The nurse is preparing a 4-day-old I infant with a serum bilirubin level of
19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching
the parents about home phototherapy, which instruction should the nurse
include in the discharge teaching plan?
• Reposition the infant every 2 hours.
• Perform diaper changes under the light.
• Feed the infant every 4 hours.
• Cover with a receiving blanket.
, • Rational: An infant, who is receiving phototherapy for
hyperbilirubinemia, should be repositioned every two hours. The
position changes ensure that the phototherapy lights reach all of the
body surface areas. Bathing, feedings, and diaper changes are ways
for the parents to bond with the infant, and can occur away from the
treatment. Feedings need to occur more frequently than every 4 hours
to prevent dehydration. The infant should wear only a diaper so that
the skin is exposed to the phototherapy.
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.
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
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
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.
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
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate first?
• Respiratory apnea of 30 seconds
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
When planning care for a client with acute pancreatitis, which nursing
intervention has the highest priority?
