HESI PN COMPREHENSIVE EXAM 3
QUESTION AND ANSWERS 2024/2025
UPDATED
A client with deep partial-thickness and full-thickness burns of the face and chest
is receiving wound care using the open method. The plan of care includes the
Nsg Dx, "Risk for infection R/T impaired tissue integrity." Based on the expected
outcome, "Client remains free of infections," which nursing interventions should
the PN implement?
A. Wear gown, cap, mask, and gloves during direct client care.
B. Restrict visitors in order to prevent wound contamination.
C. Use sterile water for debridement in the hydrotherapy tank.
D. Apply sterile dressings after debridement of burn wounds.
A. Wear gown, cap, mask, and gloves during direct client care.
No dressing is used for burn wound care using the open method. The burn area is
exposed and an aseptic environment is needed to prevent contamination and infection.
Protective isolation precautions should be implemented during direct client care and
wound care, which should include wearing gown, cap, mask, and gloves.
What action should the PN implement to facilitate speech for a client who has a
fenestrated tracheostomy tube?
A. Show the client how to use a tracheostomy plug.
B. Determine the client's ability to swallow.
C. Remove the inner cannula.
D. Give oxygen at 6 L/minute via tracheostomy collar.
B. Determine the client's ability to swallow.
A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer
cannula that allows airflow over the vocal cords and speech in a client who is
spontaneously breathing. It does not have a cuff, so the client's risk for aspiration should
be determined.
A male client scheduled for a total laryngectomy and radical neck dissection for
cancer of the larynx asks the PN if he will ever be able to speak. Which response
is bets for the PN to provide?
A. Breathing occurs through a permanent neck opening which prevents normal
speech.
B. Permanent removal of the voice box requires rehabilitation for esophageal
speech.
C. Due to removal of the vocal cords, communication requires the use of sign
,language.
D. Once the breathing hole in the neck heals, the ability to speak requires a
device.
B. Permanent removal of the voice box requires rehabilitation for esophageal speech.
A total laryngectomy includes removal of the larynx and pre-epiglottis region resulting in
a permanent tracheostomy and loss of normal speech abilities. Rehab is required to
learn to speak using a prosthesis, esophageal speech, or an electrolarynx.
A client is wearing a continuous 24-hour Holter monitor for elevation of heart
rhythm disturbances. What info should the PN reinforce with this client?
A. Remove the electrodes to shower or bathe
B. Keep a diary of activities as long as the monitor is worn.
C. Exercise as much as possible while the monitor is in place.
D. Call the assigned number if an episode of irregular heartbeats occurs.
B. Keep a diary of activities as long as the monitor is worn.
Nursing care for a client with a Holter monitor includes preparation of the skin,
placement of the electrodes and leads, and activities of daily living, so the client should
be informed of the importance of keeping an accurate record of activities and symptoms
The PN is caring for a client who is receiving a therapeutic dose of warfarin
(Coumadin). The client asks the PN to explain the effect of eating green leafy
vegetables. What info should the PN provide?
A. The high content of vitamin K in green leafy vegetables decreases Coumadin's
action.
B. Green vegetables are high in fiber and cellulose that decrease the absorption
of Coumadin.
C. These foods have a natural anticoagulant effect that potentiates the effect of
Coumadin.
D. Dietary intake of green leafy vegetables alters the bowel bacteria's production
of vitamin K.
A. The high content of vitamin K in green leafy vegetables decreases Coumadin's
action.
Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin K in the
production of prothrombin, which is a component of the blood clotting cascade. Green
leafy vegetables are high in vitamin K, which counteracts the anticoagulant effect of
Coumadin.
The PN is reviewing the effects of NSAIDs (nonsteroidal anti-inflammatory drugs)
with a client who has acute gastritis. What info is correct about the action of
NSAIDs?
A. Causes histamine receptor stimulation that increases the release of
hydrochloric acid.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach
, lining.
C. Activates an inflammatory response which increases the drug's absorption.
C.
D. Stimulates parietal cells to release pepsin leading to digestion of ingested
foods.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining
NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining.
After undergoing exploratory laparotomy and bowel resection, a client with an NG
tube to suction complains of nausea and stomach distention. The PN irrigates the
tube, but the irrigating fluid does not return. What action should the PN
implement?
A. Notify the healthcare provider.
B. Auscultate for bowel sounds.
C. Reposition the tube and check for placement.
D. Remove the tube and replace it with a new one.
C. Reposition the tube and check for placement.
Patency and position of a NGT are checked frequently to evaluate for dislodgement or
NGT obstruction with mucous, sediment, or blood clots. The placement should be
verified and repositioned in the stomach to obtain a return of the normal saline used to
irrigate the NGT.
A client with advanced cirrhosis is prescribed lactulose (Cephulac) 30 ml QID.
The client complains that the medicine is causing diarrhea. Which therapeutic
response of the medication should the PN provide the client?
A. Promotes fluid loss.
B. Prevents constipation.
C. Excretes ammonia to improve cerebral function.
D. Reduces the risk for gastrointestinal bleeding.
C. Excretes ammonia to improve cerebral function.
To treat portal-systemic encephalopathy, lactulose causes the movement of serum
ammonia, which accumulates due to hepatic dysfunction in cirrhosis, into the gut and
results in diarrhea due to the osmotic movement of water.
The PN is reinforcing the discharge instructions for a female client with cystitis.
Which statement indicates to the PN that the client understands measures to
prevent urinary tract infections (UTI)?
A. "I will limit my fluid intake to 1000 ml/day to prevent symptoms of frequency
and urgency."
B. "Every 2 to 3 hours during waking hours, I will drink a glass of water and
empty my bladder."
C. "I will use an antiseptic vaginal deodorant spray to reduce perineal bacterial
QUESTION AND ANSWERS 2024/2025
UPDATED
A client with deep partial-thickness and full-thickness burns of the face and chest
is receiving wound care using the open method. The plan of care includes the
Nsg Dx, "Risk for infection R/T impaired tissue integrity." Based on the expected
outcome, "Client remains free of infections," which nursing interventions should
the PN implement?
A. Wear gown, cap, mask, and gloves during direct client care.
B. Restrict visitors in order to prevent wound contamination.
C. Use sterile water for debridement in the hydrotherapy tank.
D. Apply sterile dressings after debridement of burn wounds.
A. Wear gown, cap, mask, and gloves during direct client care.
No dressing is used for burn wound care using the open method. The burn area is
exposed and an aseptic environment is needed to prevent contamination and infection.
Protective isolation precautions should be implemented during direct client care and
wound care, which should include wearing gown, cap, mask, and gloves.
What action should the PN implement to facilitate speech for a client who has a
fenestrated tracheostomy tube?
A. Show the client how to use a tracheostomy plug.
B. Determine the client's ability to swallow.
C. Remove the inner cannula.
D. Give oxygen at 6 L/minute via tracheostomy collar.
B. Determine the client's ability to swallow.
A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer
cannula that allows airflow over the vocal cords and speech in a client who is
spontaneously breathing. It does not have a cuff, so the client's risk for aspiration should
be determined.
A male client scheduled for a total laryngectomy and radical neck dissection for
cancer of the larynx asks the PN if he will ever be able to speak. Which response
is bets for the PN to provide?
A. Breathing occurs through a permanent neck opening which prevents normal
speech.
B. Permanent removal of the voice box requires rehabilitation for esophageal
speech.
C. Due to removal of the vocal cords, communication requires the use of sign
,language.
D. Once the breathing hole in the neck heals, the ability to speak requires a
device.
B. Permanent removal of the voice box requires rehabilitation for esophageal speech.
A total laryngectomy includes removal of the larynx and pre-epiglottis region resulting in
a permanent tracheostomy and loss of normal speech abilities. Rehab is required to
learn to speak using a prosthesis, esophageal speech, or an electrolarynx.
A client is wearing a continuous 24-hour Holter monitor for elevation of heart
rhythm disturbances. What info should the PN reinforce with this client?
A. Remove the electrodes to shower or bathe
B. Keep a diary of activities as long as the monitor is worn.
C. Exercise as much as possible while the monitor is in place.
D. Call the assigned number if an episode of irregular heartbeats occurs.
B. Keep a diary of activities as long as the monitor is worn.
Nursing care for a client with a Holter monitor includes preparation of the skin,
placement of the electrodes and leads, and activities of daily living, so the client should
be informed of the importance of keeping an accurate record of activities and symptoms
The PN is caring for a client who is receiving a therapeutic dose of warfarin
(Coumadin). The client asks the PN to explain the effect of eating green leafy
vegetables. What info should the PN provide?
A. The high content of vitamin K in green leafy vegetables decreases Coumadin's
action.
B. Green vegetables are high in fiber and cellulose that decrease the absorption
of Coumadin.
C. These foods have a natural anticoagulant effect that potentiates the effect of
Coumadin.
D. Dietary intake of green leafy vegetables alters the bowel bacteria's production
of vitamin K.
A. The high content of vitamin K in green leafy vegetables decreases Coumadin's
action.
Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin K in the
production of prothrombin, which is a component of the blood clotting cascade. Green
leafy vegetables are high in vitamin K, which counteracts the anticoagulant effect of
Coumadin.
The PN is reviewing the effects of NSAIDs (nonsteroidal anti-inflammatory drugs)
with a client who has acute gastritis. What info is correct about the action of
NSAIDs?
A. Causes histamine receptor stimulation that increases the release of
hydrochloric acid.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach
, lining.
C. Activates an inflammatory response which increases the drug's absorption.
C.
D. Stimulates parietal cells to release pepsin leading to digestion of ingested
foods.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining
NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining.
After undergoing exploratory laparotomy and bowel resection, a client with an NG
tube to suction complains of nausea and stomach distention. The PN irrigates the
tube, but the irrigating fluid does not return. What action should the PN
implement?
A. Notify the healthcare provider.
B. Auscultate for bowel sounds.
C. Reposition the tube and check for placement.
D. Remove the tube and replace it with a new one.
C. Reposition the tube and check for placement.
Patency and position of a NGT are checked frequently to evaluate for dislodgement or
NGT obstruction with mucous, sediment, or blood clots. The placement should be
verified and repositioned in the stomach to obtain a return of the normal saline used to
irrigate the NGT.
A client with advanced cirrhosis is prescribed lactulose (Cephulac) 30 ml QID.
The client complains that the medicine is causing diarrhea. Which therapeutic
response of the medication should the PN provide the client?
A. Promotes fluid loss.
B. Prevents constipation.
C. Excretes ammonia to improve cerebral function.
D. Reduces the risk for gastrointestinal bleeding.
C. Excretes ammonia to improve cerebral function.
To treat portal-systemic encephalopathy, lactulose causes the movement of serum
ammonia, which accumulates due to hepatic dysfunction in cirrhosis, into the gut and
results in diarrhea due to the osmotic movement of water.
The PN is reinforcing the discharge instructions for a female client with cystitis.
Which statement indicates to the PN that the client understands measures to
prevent urinary tract infections (UTI)?
A. "I will limit my fluid intake to 1000 ml/day to prevent symptoms of frequency
and urgency."
B. "Every 2 to 3 hours during waking hours, I will drink a glass of water and
empty my bladder."
C. "I will use an antiseptic vaginal deodorant spray to reduce perineal bacterial
