2023 HESI PN EXIT EXAM 110
q q q q q
QUESTIONS AND q
ANSWER(S) q
1. Anqadultqclientqexperiencesqaqgasolineqtankqfireqwhenqridingqaqmotorcycleqandqisqadmittedqtoqt
heqemergencyqdepartmentq(ED)qwithqfullqthicknessqburnsqtoqallqsurfacesqofqbothqlowerqextrem
ities.qWhatqpercentageqofqbodyqsurfaceqareaqshouldqtheqnurseqdocumentqinqtheqelectronicqmedi
calqrecordq(EMR)?
• 9q%
• 18q%
• 36q%
• 45q%
• Rational:qaccordingqtoqtheqruleqofqnines,qtheqanteriorqandqposteriorqsurfacesqofqoneql
owerqextremityqisqdesignatedqasq18q%ofqtotalqbodyqsurfaceqareaq(TBSA),qsoqbothqe
xtremitiesqequalsq36%qTBSA,qotherqoptionsqareqincorrect.
2. Aqclientqwithqhyperthyroidismqisqreceivingqpropranololq(Inderal).qWhichqfindingqindicatesqthatqt
heqmedicationqisqhavingqtheqdesiredqeffect?
• DecreaseqinqserumqT4qlevels
• Increaseqinqbloodqpressure
• Decreaseqinqpulseqrate
• Goiterqnoqlongerqpalpable
3. Anqolderqmaleqclientqwithqtypeq2qdiabetesqmellitusqreportsqthatqhasqexperiencesqlegsqpainqw
henqwalkingqshortqdistances,qandqthatqtheqpainqisqrelievedqbyqrest.qWhichqclientqbehaviorqind
icatesqanqunderstandingqofqhealthcareqteachingqtoqpromoteqmoreqeffectiveqarterialqcirculati
on?
• ConsistentlyqappliesqTEDqhoseqbeforeqgettingqdressedqinqtheqmorning.
• Frequentlyqelevatedqlegsqthoroughqtheqday.
• Inspectqtheqlegqfrequentlyqforqanyqirritationqorqskinqbreakdown
• Completelyqstopqcigarette/qcigarqsmoking.
• Rationale:qStoppingqcigaretteqsmokingqhelpsqtoqdecreaseqvasoconstrictionqandqi
mproveqarterialqcirculationqtoqtheqextremity.
,4. Aqcommunityqhealthqnurseqisqconcernedqaboutqtheqspreadqofqcommunicableqdiseasesqamongqmi
grantqfarmqworkersqinqaqruralqcommunity.qWhatqactionqshouldqtheqnurseqtakeqtoqpromoteqtheqsucc
essqofqaqhealthcareqprogramqdesignedqtoqaddressqthisqproblem?
• Establishqtrustqwithqcommunityqleadersqandqrespectqculturalqandqfamilyq
values
5. Theqnurseqperformsqaqprescribedqneurologicalqcheckqatqtheqbeginningqofqtheqshiftqonqaqclientq
whoqwasqadmittedqtoqtheqhospitalqwithqaqsubarachnoidqbrainqattackq(stroke).qTheqclient’sqGla
sgowqComaqScaleq(GCS)qscoreqisq9.qWhatqinformationqisqmostqimportantqforqtheqnurseqtoqdeter
mine?
• Theqclient’sqpreviousqGCSqscore
• Whenqtheqclient’sqstrokeqsymptomsqstarted
• Ifqtheqclientqisqorientedqtoqtime
• Theqclient’sqbloodqpressureqandqrespirationqrate
• Rationale:qTheqnormalqGCSqisq15,qandqitqisqmostqimportantqforqtheqnurseqtoqdet
ermineqifqitqabnormalqscoreqaqsignqofqimprovementqorqaqdeteriorationqinqtheqclie
nt’sqcondition
6. Theqchargeqnurseqinqaqcriticalqcarequnitqisqreviewingqclients’qconditionsqtoqdetermineqwhoqisqst
ableqenoughqtoqbeqtransferred.qWhichqclientqstatusqreportqindicatesqreadinessqforqtransferqfro
mqtheqcriticalqcarequnitqtoqaqmedicalqunit?
• Chronicqliverqfailureqwithqaqhemoglobinqofq10.1qandqslightqbilirubinqelevation
7. Basedqonqprinciplesqofqasepsis,qtheqnurseqshouldqconsiderqwhichqcircumstanceqtoqbeqsterile?
• Oneqinch-qborderqaroundqtheqedgeqofqtheqsterileqfieldqsetqupqinqtheqoperatingqroom
• Aqwrappedqunopened,qsterileq4x4qgauzeqplacedqonqaqdampqtableqtop.
• AnqopenqsterileqFoleyqcatheterqkitqsetqupqonqaqtableqatqtheqnurseqwaistqlevel
• Sterileqsyringeqisqplacedqonqsterileqareaqasqtheqnurseqrichesqoverqtheqsterileqfield.
• Rationale:qAqsterileqpackageqatqorqaboveqtheqwaistqlevelqisqconsideredqsterile.qTheqe
dgeqofqsterileqfieldqisqcontaminatedqwhichqincludeqaq1-inchqborderq(A).qAqsterile
objectsqbecomeqcontaminatedqbyqcapillaryqactionqwhenqsterileqobjectsqbecomeqinqc
ontactqwithqaqwetqcontaminatedqsurface.
8. Anqunlicensedqassistiveqpersonnelq(UAP)qreportsqthatqaqclient’sqrightqhandqandqfingersqspasmsq
whenqtakingqtheqbloodqpressurequsingqtheqsameqarm.qAfterqconfirmingqtheqpresenceqofqspamsq
whatqactionqshouldqtheqnurseqtake?
• AskqtheqUAPqtoqtakeqtheqbloodqpressureqinqtheqotherqarm
, HESIqV3qPNqEXITqEXAMq110qQUESTIONSqANDqANSWER
• TellqtheqUAPqtoquseqaqdifferentqsphygmomanometer.
• Reviewqtheqclient’sqserumqcalciumqlevel
• AdministerqPRNqantianxietyqmedication.
• Rationale:qTrousseau’sqsignqisqindicatedqbyqspasmsqinqtheqdistalqportionqofqanqe
xtremityqthatqisqbeingqusedqtoqmeasureqbloodqpressureqandqisqcausedqbyqhypoc
alcemiaq(normalqlevelq9.0-10.5qmg/dl,qsoqCqshouldqbeqimplemented.
9. Aq56-years-
oldqmanqsharesqwithqtheqnurseqthatqheqisqhavingqdifficultyqmakingqdecisionqaboutqterminatingql
ifeqsupportqforqhisqwife.qWhatqisqtheqbestqinitialqactionqbyqtheqnurse?
• Provideqanqopportunityqforqhimqtoqclarifyqhisqvaluesqrelatedqtoqtheqdecision
• Encourageqhimqtoqshareqmemoriesqaboutqhisqlifeqwithqhisqwifeqandqfamily
• Adviseqhimqtoqseekqseveralqopinionsqbeforeqmakingqdecision
• Offerqtoqcontactqtheqhospitalqchaplainqorqsocialqworkerqtoqofferqsupport.
• Rationale:qWhenqaqclientqisqfacedqwithqaqdecisionalqconflict,qtheqnurseqshouldqfirstqp
rovideqopportunitiesqforqtheqclientqtoqclarifyqvaluesqimportantqinqtheqdecision.qTheqre
stqmayqalsoqbeqbeneficialqonceqtheqclientqasqclarifiedqtheqvaluesqthatqare
importantqtoqhimqinqtheqdecision-makingqprocess.
10. Aqclientqisqbeingqdischargedqhomeqafterqbeingqtreatedqforqheartqfailureq(HF).qWhatqinstructionqs
houldqtheqnurseqincludeqinqthisqclient’sqdischargeqteachingqplan?
• Weighqeveryqmorning
• Eatqaqhighqproteinqdiet
• Performqrangeqofqmotionqexercises
• Limitqfluidqintakeqtoq1,500qmlqdaily
11. AqwomanqjustqlearnedqthatqsheqwasqinfectedqwithqHeliobacterqpylori.qBasedqonqthisqfinding,q
whichqhealthqpromotionqpracticeqshouldqtheqnurseqsuggest?
• Encourageqscreeningqforqaqpepticqulcer
12. Aqclientqwhoqrecentlyqunderwearqaqtracheostomyqisqbeingqpreparedqforqdischargeqtoqhome.
Whichqinstructionsqisqmostqimportantqforqtheqnurseqtoqincludeqinqtheqdischargeqplan?
• Teachqtrachealqsuctioningqtechniques
13. Aqchildqwithqheartqfailureqisqreceivingqtheqdiureticqfurosemideq(Lasix)qandqhasqserumqpota
ssiumqlevelq3.0qmEq/L.qWhichqassessmentqisqmostqimportantqforqtheqnurseqtoqobtain?
• Cardiacqrhythmqandqheartqrate.
• Dailyqintakeqofqfoodsqrichqinqpotassium.
q q q q q
QUESTIONS AND q
ANSWER(S) q
1. Anqadultqclientqexperiencesqaqgasolineqtankqfireqwhenqridingqaqmotorcycleqandqisqadmittedqtoqt
heqemergencyqdepartmentq(ED)qwithqfullqthicknessqburnsqtoqallqsurfacesqofqbothqlowerqextrem
ities.qWhatqpercentageqofqbodyqsurfaceqareaqshouldqtheqnurseqdocumentqinqtheqelectronicqmedi
calqrecordq(EMR)?
• 9q%
• 18q%
• 36q%
• 45q%
• Rational:qaccordingqtoqtheqruleqofqnines,qtheqanteriorqandqposteriorqsurfacesqofqoneql
owerqextremityqisqdesignatedqasq18q%ofqtotalqbodyqsurfaceqareaq(TBSA),qsoqbothqe
xtremitiesqequalsq36%qTBSA,qotherqoptionsqareqincorrect.
2. Aqclientqwithqhyperthyroidismqisqreceivingqpropranololq(Inderal).qWhichqfindingqindicatesqthatqt
heqmedicationqisqhavingqtheqdesiredqeffect?
• DecreaseqinqserumqT4qlevels
• Increaseqinqbloodqpressure
• Decreaseqinqpulseqrate
• Goiterqnoqlongerqpalpable
3. Anqolderqmaleqclientqwithqtypeq2qdiabetesqmellitusqreportsqthatqhasqexperiencesqlegsqpainqw
henqwalkingqshortqdistances,qandqthatqtheqpainqisqrelievedqbyqrest.qWhichqclientqbehaviorqind
icatesqanqunderstandingqofqhealthcareqteachingqtoqpromoteqmoreqeffectiveqarterialqcirculati
on?
• ConsistentlyqappliesqTEDqhoseqbeforeqgettingqdressedqinqtheqmorning.
• Frequentlyqelevatedqlegsqthoroughqtheqday.
• Inspectqtheqlegqfrequentlyqforqanyqirritationqorqskinqbreakdown
• Completelyqstopqcigarette/qcigarqsmoking.
• Rationale:qStoppingqcigaretteqsmokingqhelpsqtoqdecreaseqvasoconstrictionqandqi
mproveqarterialqcirculationqtoqtheqextremity.
,4. Aqcommunityqhealthqnurseqisqconcernedqaboutqtheqspreadqofqcommunicableqdiseasesqamongqmi
grantqfarmqworkersqinqaqruralqcommunity.qWhatqactionqshouldqtheqnurseqtakeqtoqpromoteqtheqsucc
essqofqaqhealthcareqprogramqdesignedqtoqaddressqthisqproblem?
• Establishqtrustqwithqcommunityqleadersqandqrespectqculturalqandqfamilyq
values
5. Theqnurseqperformsqaqprescribedqneurologicalqcheckqatqtheqbeginningqofqtheqshiftqonqaqclientq
whoqwasqadmittedqtoqtheqhospitalqwithqaqsubarachnoidqbrainqattackq(stroke).qTheqclient’sqGla
sgowqComaqScaleq(GCS)qscoreqisq9.qWhatqinformationqisqmostqimportantqforqtheqnurseqtoqdeter
mine?
• Theqclient’sqpreviousqGCSqscore
• Whenqtheqclient’sqstrokeqsymptomsqstarted
• Ifqtheqclientqisqorientedqtoqtime
• Theqclient’sqbloodqpressureqandqrespirationqrate
• Rationale:qTheqnormalqGCSqisq15,qandqitqisqmostqimportantqforqtheqnurseqtoqdet
ermineqifqitqabnormalqscoreqaqsignqofqimprovementqorqaqdeteriorationqinqtheqclie
nt’sqcondition
6. Theqchargeqnurseqinqaqcriticalqcarequnitqisqreviewingqclients’qconditionsqtoqdetermineqwhoqisqst
ableqenoughqtoqbeqtransferred.qWhichqclientqstatusqreportqindicatesqreadinessqforqtransferqfro
mqtheqcriticalqcarequnitqtoqaqmedicalqunit?
• Chronicqliverqfailureqwithqaqhemoglobinqofq10.1qandqslightqbilirubinqelevation
7. Basedqonqprinciplesqofqasepsis,qtheqnurseqshouldqconsiderqwhichqcircumstanceqtoqbeqsterile?
• Oneqinch-qborderqaroundqtheqedgeqofqtheqsterileqfieldqsetqupqinqtheqoperatingqroom
• Aqwrappedqunopened,qsterileq4x4qgauzeqplacedqonqaqdampqtableqtop.
• AnqopenqsterileqFoleyqcatheterqkitqsetqupqonqaqtableqatqtheqnurseqwaistqlevel
• Sterileqsyringeqisqplacedqonqsterileqareaqasqtheqnurseqrichesqoverqtheqsterileqfield.
• Rationale:qAqsterileqpackageqatqorqaboveqtheqwaistqlevelqisqconsideredqsterile.qTheqe
dgeqofqsterileqfieldqisqcontaminatedqwhichqincludeqaq1-inchqborderq(A).qAqsterile
objectsqbecomeqcontaminatedqbyqcapillaryqactionqwhenqsterileqobjectsqbecomeqinqc
ontactqwithqaqwetqcontaminatedqsurface.
8. Anqunlicensedqassistiveqpersonnelq(UAP)qreportsqthatqaqclient’sqrightqhandqandqfingersqspasmsq
whenqtakingqtheqbloodqpressurequsingqtheqsameqarm.qAfterqconfirmingqtheqpresenceqofqspamsq
whatqactionqshouldqtheqnurseqtake?
• AskqtheqUAPqtoqtakeqtheqbloodqpressureqinqtheqotherqarm
, HESIqV3qPNqEXITqEXAMq110qQUESTIONSqANDqANSWER
• TellqtheqUAPqtoquseqaqdifferentqsphygmomanometer.
• Reviewqtheqclient’sqserumqcalciumqlevel
• AdministerqPRNqantianxietyqmedication.
• Rationale:qTrousseau’sqsignqisqindicatedqbyqspasmsqinqtheqdistalqportionqofqanqe
xtremityqthatqisqbeingqusedqtoqmeasureqbloodqpressureqandqisqcausedqbyqhypoc
alcemiaq(normalqlevelq9.0-10.5qmg/dl,qsoqCqshouldqbeqimplemented.
9. Aq56-years-
oldqmanqsharesqwithqtheqnurseqthatqheqisqhavingqdifficultyqmakingqdecisionqaboutqterminatingql
ifeqsupportqforqhisqwife.qWhatqisqtheqbestqinitialqactionqbyqtheqnurse?
• Provideqanqopportunityqforqhimqtoqclarifyqhisqvaluesqrelatedqtoqtheqdecision
• Encourageqhimqtoqshareqmemoriesqaboutqhisqlifeqwithqhisqwifeqandqfamily
• Adviseqhimqtoqseekqseveralqopinionsqbeforeqmakingqdecision
• Offerqtoqcontactqtheqhospitalqchaplainqorqsocialqworkerqtoqofferqsupport.
• Rationale:qWhenqaqclientqisqfacedqwithqaqdecisionalqconflict,qtheqnurseqshouldqfirstqp
rovideqopportunitiesqforqtheqclientqtoqclarifyqvaluesqimportantqinqtheqdecision.qTheqre
stqmayqalsoqbeqbeneficialqonceqtheqclientqasqclarifiedqtheqvaluesqthatqare
importantqtoqhimqinqtheqdecision-makingqprocess.
10. Aqclientqisqbeingqdischargedqhomeqafterqbeingqtreatedqforqheartqfailureq(HF).qWhatqinstructionqs
houldqtheqnurseqincludeqinqthisqclient’sqdischargeqteachingqplan?
• Weighqeveryqmorning
• Eatqaqhighqproteinqdiet
• Performqrangeqofqmotionqexercises
• Limitqfluidqintakeqtoq1,500qmlqdaily
11. AqwomanqjustqlearnedqthatqsheqwasqinfectedqwithqHeliobacterqpylori.qBasedqonqthisqfinding,q
whichqhealthqpromotionqpracticeqshouldqtheqnurseqsuggest?
• Encourageqscreeningqforqaqpepticqulcer
12. Aqclientqwhoqrecentlyqunderwearqaqtracheostomyqisqbeingqpreparedqforqdischargeqtoqhome.
Whichqinstructionsqisqmostqimportantqforqtheqnurseqtoqincludeqinqtheqdischargeqplan?
• Teachqtrachealqsuctioningqtechniques
13. Aqchildqwithqheartqfailureqisqreceivingqtheqdiureticqfurosemideq(Lasix)qandqhasqserumqpota
ssiumqlevelq3.0qmEq/L.qWhichqassessmentqisqmostqimportantqforqtheqnurseqtoqobtain?
• Cardiacqrhythmqandqheartqrate.
• Dailyqintakeqofqfoodsqrichqinqpotassium.
