HESI PN Clinical Analysis Exit Exam Version 3 With Answers (100 Solved Questions)

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HESI PN Clinical Analysis Exit Exam Version 3 With Answers (100 Solved Questions) - Page 1 preview image

HESI PN EXIT EXAM V3 110 QUESTIONSAND ANSWER(S)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 lowerextremities. What percentage of body surface area should the nurse document in theelectronic 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.A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates thatthe medication is having the desired effect?•Decrease in serum T4 levels•Increase in blood pressure•Decrease in pulse rate•Goiter no longer palpable3.An older male client with type 2 diabetes mellitus reports that has experiences legs painwhen walking short distances, and that the pain is relieved by rest. Which clientbehavior indicates an understanding of healthcare teaching to promote more effectivearterial 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 andimprove arterial circulation to the extremity.pg. 1lOMoARcPSD|13778330

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4.A community health nurse is concerned about the spread of communicable diseases amongmigrant farm workers in a rural community. What action should the nurse take to promotethe success of a healthcare program designed to address this problem?•Establish trust with community leaders and respect cultural andfamily values5.The nurse performs a prescribed neurological check at the beginning of the shift on a clientwho was admitted to the hospital with a subarachnoid brain attack (stroke). The client’sGlasgow Coma Scale (GCS) score is 9. What information is most important for the nurseto 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•Rationale: The normal GCS is 15, and it is most important for the nurse todetermine if it abnormal score a sign of improvement or a deterioration inthe client’s condition6.The charge nurse in a critical care unit is reviewing clients’ conditions to determine who isstable enough to be transferred. Which client status report indicates readiness for transferfrom the critical care unit to a medical unit?•Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation7.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. Theedge of sterile field is contaminated which include a 1-inch border (A). A sterileobjects become contaminated by capillary action when sterile objects become incontact with a wet contaminated surface.8.An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasmswhen taking the blood pressure using the same arm. After confirming the presence of spamswhat action should the nurse take?•Ask the UAP to take the blood pressure in the other armpg. 2

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•Tell the UAP to use a different sphygmomanometer.•Review the client’s serum calcium level•Administer PRN antianxiety medication.•Rationale: Trousseau’s sign is indicated by spasms in the distal portion ofan extremity that is being used to measure blood pressure and is caused byhypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.9.A 56-years-old man shares with the nurse that he is having difficulty making decision aboutterminating 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 client is faced with a decisional conflict, the nurse should firstprovide opportunities for the client to clarify values important in the decision.The rest may also be beneficial once the client as clarified the values that areimportant to him in the decision-making process.10. A client is being discharged home after being treated for heart failure (HF). What instructionshould 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 daily11. 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 ulcer12. A client who recently underwear a tracheostomy is being prepared for discharge to home.Which instructions is most important for the nurse to include in the discharge plan?•Teach tracheal suctioning techniques13. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serumpotassium level 3.0 mEq/L. Which assessment is most important for the nurse toobtain?•Cardiac rhythm and heart rate.•Daily intake of foods rich in potassium.pg. 3

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•Hourly urinary output•Thirst ad skin turgor.14. The nurse note a depressed female client has been more withdrawn and non-communicativeduring the past two weeks. Which intervention is most important to include in the updatedplan of care for this client?•Encourage the client’s family to visit more often•Schedule a daily conference with the social worker•Encourage the client to participate in group activities•Engage the client in a non-threatening conversation.•Rationale: Consistent attempts to draw the client into conversations which focuson non-threatening subjects can be an effective means of eliciting a response,thereby decreasing isolation behaviors. There is not sufficient data to support theeffectiveness of A as an intervention for this client. Although B may beindicated, nursing interventions can also be used to treat this client. C is toothreatening to this client.15. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)subcutaneously once weekly. The nurse should emphasize the importance of reportingproblem to the healthcare provider?•Headache•Joint stiffness•Persistent fever•Increase hunger and thirst•Rationale: Enbrel decrease immune and inflammatory responses, increasing theclient’s risk of serious infection, so the client should be instructed to report apersistent fever, or other signs of infection to the healthcare provider.16. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessmentfinding indicates that the client understands long- term control of diabetes?•The fating blood sugar was 120 mg/dl this morning.•Urine ketones have been negative for the past 6 months•The hemoglobin A1C was 6.5g/100 ml last week•No diabetic ketoacidosis has occurred in 6 months.•Rationale: A hemoglobin A1C level reflects he average blood sugar the clienthad over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that theclientpg. 4

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understand long-term diabetes control. Normal value in a diabetic patient is up to6.5 g/100 ml.17. An older male client is admitted with the medical diagnosis of possible cerebral vascularaccident (CVA). He has facial paralysis and cannot move his left side. When entering theroom, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink ofwater. What action should the nurse take?•Ask the wife to stop and assess the client’s swallowing reflex18. 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 andsensitivity and applies a cast to the adolescent’s lower leg. What action should the nurseimplement 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 andimmobilization. After bond and blood aspirate specimens are obtained forculture and sensitivity, the nurse should initiate parenteral antibiotics asprescribed.19. The nurse is preparing a community education program on osteoporosis. Which instructionis helpful in preventing bone loss and promoting bone formation?•Recommend weigh bearing physical activity20. 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 actionshould the nurse implement next?•Administer the analgesic as requested21. 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.pg. 5

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•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.22. The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impairedmovements will worsen as the child grows. Which response provides the bestexplanation?•Brain damage with CP is not progressive but does have a variable course23. During shift report, the central electrocardiogram (EKG) monitoring system alarms.Which client alarm should the nurse investigate first?•Respiratory apnea of 30 seconds24. In early septic shock states, what is the primary cause of hypotension?•Peripheral vasoconstriction•Peripheral vasodilation•Cardiac failure•A vagal response•Rationale:Toxinsreleasedbybacteriainsepticshockcreatemassiveperipheral vasodilation and increase microvascular permeability at the site ofthe bacterial invasion.25. A client diagnosed with calcium kidney stones has a history of gout. A new prescriptionfor aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which clientmedication should the nurse bring to the healthcare provider’s attention?•Allopurinol (Zyloprim)•Aspirin, low dose•Furosemide (lasix)•Enalapril (vasote)26. A male client’s laboratory results include a platelet count of 105,000/ mm3 Based on thisfinding the nurse should include which action in the client’s plan of care?•Cluster care to conserve energy•Initiate contact isolation•Encourage him to use an electric razor•Asses him for adventitious lung soundspg. 6

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•Rationale: This client is at risk for bleeding based on his platelet count(normal 150,000 to 400,000/ mm3). Safe practices, such as using an electricrazor for shaving, should be encouraged to reduce the risk of bleeding.27. A client is admitted to the hospital after experiencing a brain attack, commonly referred to asa stroke or cerebral vascular accident (CVA). The nurse should request a referral for speechtherapy if the client exhibits which finding?•Abnormal responses for cranial nerves I and II•Persistent coughing while drinking•Unilateral facial drooping•Inappropriate or exaggerated mood swings28. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews theclient’s medical record. Based on date contained in the record, what action should the nursetake before assisting the client with ambulation:•Remove sequential compression devices.•Apply PRN oxygen per nasal cannula.•Administer a PRN dose of an antipyretic.•Reinforce the surgical wound dressing.•Rationale: Sequential compression devices should be removed prior to ambulationand there is no indication that this action is contraindicated. The client’s oxygensaturation levels have been within normal limits for the previous four hours, sosupplemental oxygen is not warranted.29. Which assessment finding for a client who is experiencing pontine myelinolysis should thenurse report to the healthcare provider?•Sudden dysphagia•Blurred visual field•Gradual weakness•Profuse diarrhea30. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours afterreceiving chemotherapy. The client has saline lock and is sleeping quietly without anyrestlessness. The nurse caring for the client is not certified in chemotherapyadministration. What action should the nurse take?•Ask a chemotherapy-certified nurse to administer the Zofran•Administer the Zofran after flushing the saline lock with salinepg. 7

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•Hold the scheduled dose of Zofran until the client awakens•Awaken the client to assess the need for administration of the Zofran.•Rationale: Zofran is an antiemetic administered before and after chemotherapy toprevent vomiting. The nurse should administer the antiemetic using the acceptertechnique for IV administration via saline lock. Zofran is not a chemotherapydrug and does not need to be administered by a chemotherapy- certified nurse.31. When providing diet teaching for a client with cholecystitis, which types of food choicesthe nurse recommend to the client?•High protein•Low fat•Low sodium•High carbohydrate.•Rationale: A client with cholecystitis is at risk of gall stones that can be move intothe biliary tract and cause pain or obstruction. Reducing dietary fat decreasestimulation of the gall bladder, so bile can be expelled, along with possible stones,into the biliary tract and small intestine.32. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea andascites. Which assessment finding warrants immediate intervention by the nurse?•Jaundice skin tone•Muffled heart sounds•Pitting peripheral edema•Bilateral scleral edema•Rationale: Muffled heart sounds may indicative fluid build-up in the pericardiumand is life- threatening. The other one are signs of end stage liver disease relatedto alcoholism but are not immediately life- threatening.33. When entering a client’s room, the nurse discovers that the client is unresponsive andpulseless. The nurse initiate CPR and Calls for assistance. Which action should the nursetake next?•Prepare to administer atropine 0.4 mg IVP•Gather emergency tracheostomy equipment•Prepare to administer lidocaine at 100 mg IVP•Place cardiac monitor leads on the client’s chest.pg. 8

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