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 %
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.
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
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.
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.
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.
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.
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 %
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.
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
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.
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.
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.
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.
