HESI PN EXIT EXAM V3 100 QUESTIONS
AND ANSWER(S)|ALREADY GRADED A+
• An adult patient 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 patient 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
• An older male patient with type 2 diabetes mellitus reports that has experiences legs
pain when walking short distances, and that the pain is relieved by rest. Which patient
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
patient who was admitted to the hospital with a subarachnoid brain attack (stroke). The
patient’s Glasgow Coma Scale (GCS) score is 9. What information is most important for
the nurse to determine?
• The patient’s previous GCS score
• When the patient’s stroke symptoms started
• If the patient is oriented to time
• The patient’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 patient’s condition
• The charge nurse in a critical care unit is reviewing patients’ conditions to determine
who is stable enough to be transferred. Which patient 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
• 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.
, • An unlicensed assistive personnel (UAP) reports that a patient’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 patient’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.
• 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 patient is faced with a decisional conflict, the nurse should
first provide opportunities for the patient to clarify values important in the
decision. The rest may also be beneficial once the patient as clarified the values
that are important to him in the decision-making process.
• A patient is being discharged home after being treated for heart failure (HF). What
instruction should the nurse include in this patient’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
• 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
AND ANSWER(S)|ALREADY GRADED A+
• An adult patient 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 patient 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
• An older male patient with type 2 diabetes mellitus reports that has experiences legs
pain when walking short distances, and that the pain is relieved by rest. Which patient
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
patient who was admitted to the hospital with a subarachnoid brain attack (stroke). The
patient’s Glasgow Coma Scale (GCS) score is 9. What information is most important for
the nurse to determine?
• The patient’s previous GCS score
• When the patient’s stroke symptoms started
• If the patient is oriented to time
• The patient’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 patient’s condition
• The charge nurse in a critical care unit is reviewing patients’ conditions to determine
who is stable enough to be transferred. Which patient 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
• 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.
, • An unlicensed assistive personnel (UAP) reports that a patient’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 patient’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.
• 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 patient is faced with a decisional conflict, the nurse should
first provide opportunities for the patient to clarify values important in the
decision. The rest may also be beneficial once the patient as clarified the values
that are important to him in the decision-making process.
• A patient is being discharged home after being treated for heart failure (HF). What
instruction should the nurse include in this patient’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
• 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
