HESI PN EXIT EXAM V3 LATEST VERSION 2022-2024 ALL
110 QUESTIONS AND VERIFIED RATIONALED ANSWERS
GRADED A
1. An adult client experiences a gasoline tank fire when riding a motorcycle and is
admitted tothe 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
onelower extremity is designated as 18 %of total body surface area (TBSA),
so bothextremities equals 36% TBSA, other options are incorrect.
2. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl
(325micromol/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,
shouldbe 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.
3. A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted
withosteomyelitis. 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 cultureand sensitivity, the nurse should initiate parenteral antibiotics as
prescribed.
4. The nurse is preparing a community education program on osteoporosis. Which
instruction ishelpful in preventing bone loss and promoting bone formation?
• Recommend weigh bearing physical activity
5. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert
buthas 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
6. A male client receives a thrombolytic medication following a myocardial infarction.
Whenthe 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 theintestinal tract.
7. 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
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Whichclient alarm should the nurse investigate first?
• Respiratory apnea of 30 seconds
9. In early septic shock states, what is the primary cause of hypotension?
• Peripheral vasoconstriction
• Peripheral vasodilation
• Cardiac failure
• A vagal response
10. Rationale: Toxins released by bacteria in septic shock create massive peripheral
vasodilation and increase microvascular permeability at the site of the bacterial
invasion
11. When planning care for a client with acute pancreatitis, which nursing intervention has
the highest priority?
110 QUESTIONS AND VERIFIED RATIONALED ANSWERS
GRADED A
1. An adult client experiences a gasoline tank fire when riding a motorcycle and is
admitted tothe 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
onelower extremity is designated as 18 %of total body surface area (TBSA),
so bothextremities equals 36% TBSA, other options are incorrect.
2. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl
(325micromol/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,
shouldbe 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.
3. A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted
withosteomyelitis. 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 cultureand sensitivity, the nurse should initiate parenteral antibiotics as
prescribed.
4. The nurse is preparing a community education program on osteoporosis. Which
instruction ishelpful in preventing bone loss and promoting bone formation?
• Recommend weigh bearing physical activity
5. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert
buthas 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
6. A male client receives a thrombolytic medication following a myocardial infarction.
Whenthe 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 theintestinal tract.
7. 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
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Whichclient alarm should the nurse investigate first?
• Respiratory apnea of 30 seconds
9. In early septic shock states, what is the primary cause of hypotension?
• Peripheral vasoconstriction
• Peripheral vasodilation
• Cardiac failure
• A vagal response
10. Rationale: Toxins released by bacteria in septic shock create massive peripheral
vasodilation and increase microvascular permeability at the site of the bacterial
invasion
11. When planning care for a client with acute pancreatitis, which nursing intervention has
the highest priority?
