HESI PN EXIT EXAM V3 LATEST
VERSION 2022-2024 ALL 110
QUESTIONS AND VERIFIED
ANSWERS PLUS RATIONALES/PN
HESI EXIT EXAM V3
- 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 %
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 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 - 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.
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 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
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
client’s condition - 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 - 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 4×4 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 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
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PN HESI EXIT V1 & V2 LATEST 2022-2023
EXAM/ HESI PN V1 & V2 LATEST EXAM
221 REAL EXAM QUESTIONS AND
CORRECT ANSWERS | VERIFIED
ANSWERS AGRADE
pg. 2
- The LPN/LVN is preparing to ambulate a postoperative client after
cardiac surgery. The nurse plans to do which to enable the client to
best tolerate the ambulation? - Provide the client with a walker.
- Remove the telemetry equipment.
- Encourage the client to cough and deep breathe.
- Premedicate the client with an analgesic before ambulating.
- A client is wearing a continuous cardiac monitor, which begins to alarm
at the nurse’s station. The nurse sees no electrocardiographic
complexes on the screen. The nurse should do which first?
a. Call a code blue.
b. Call the health care provider.
c. Check the client status and lead placement.
d. Press the recorder button on the ECG console. - 3) The LPN/LVN in a medical unit is caring for a client with heart
failure. The client suddenly develops extreme dyspnea, tachycardia,
and lung crackles, and the nurse suspects pulmonary edema. The
nurse immediately notifies the registered nurse and expects which
interventions to be prescribed? Select all that apply.
a. Administering oxygen
b. Inserting a Foley catheter
c. Administering furosemide (Lasix)
d. Administering morphine sulfate intravenously
e. Transporting the client to the coronary care unit
f. Placing the client in a low-Fowler’s side-lying position - The nurse is monitoring a client following cardioversion.
Which observations should be of highest priority to the nurse?
a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness - The nurse is assisting in caring for the client immediately
after insertion of a permanent demand pacemaker via the right
pg. 3
subclavian vein. The nurse prevents dislodgement of the pacing
catheter by implementing which intervention?
a. Limiting movement and abduction of the left arm
b. Limiting movement and abduction of the right arm
c. Assisting the client to get out of bed and ambulate with a
walker 4. Having the physical therapist do active range of
motion to the right arm
- A client diagnosed with thrombophlebitis 1 day ago suddenly
complains of chest pain and shortness of breath, and the client is
visibly anxious. The LPN/LVN understands that a life-threatening
complication of this condition is which?
a. Pneumonia
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction - A 24-year-old man seeks medical attention for complaints of
claudication in the arch of the foot. The nurse also notes superficial
thrombophlebitis of the lower leg. The nurse should check the client
for which next?
a. Smoking history
b. Recent exposure to allergens
c. History of recent insect bites
d. Familial tendency toward peripheral vascular disease - The nurse has reinforced instructions to the client with
Raynaud’s disease about self-management of the disease
process. The nurse determines that the client needs further
teaching if the client states which?
a. “Smoking cessation is very important.”
b. “Moving to a warmer climate should help.”
c. “Sources of caffeine should be eliminated from the diet.” - “Taking nifedipine (Procardia) as prescribed will
decrease vessel spasm.” - A client with myocardial infarction suddenly becomes tachycardic,
shows signs of air hunger, and begins coughing frothy, pinktinged sputum. The nurse listens to breath sounds, expecting to
hear which breath sounds bilaterally?
a. Rhonchi
b. Crackles
c. Wheezes
pg. 4
d. Diminished breath sounds
- The LPN/LVN is collecting data on a client with a diagnosis ofright
sided heart failure. The nurse should expect to note which specific
characteristic of this condition?
a. Dyspnea
b. Hacking cough
c. Dependent edema
d. Crackles on lung auscultation - The LPN/LVN is checking the neurovascular status of a client who
returned to the surgical nursing unit 4 hours ago after undergoing
an aortoiliac bypass graft. The affected leg is warm, andthe nurse
notes redness and edema. The pedal pulse is palpable and
unchanged from admission. The nurse interprets that the
neurovascular status is which?
a. Moderately impaired, and the surgeon should be called
b. Normal, caused by increased blood flow through the leg
c. Slightly deteriorating, and should be monitored for another
hour
d. Adequate from an arterial approach, but venous
complications are arising - A client with a diagnosis of rapid rate atrial fibrillation asks thenurse
why the health care provider is going to perform carotid massage.
The LPN/LVN responds that this procedure may stimulate which?
a. Vagus nerve to slow the heart rate
b. Vagus nerve to increase the heart rate
c. Diaphragmatic nerve to slow the heart rate
d. Diaphragmatic nerve to increase the heart rate - A client is admitted to the hospital with possible rheumatic
endocarditis. The LPN/LVN should check for a history of which type
of infection?
a. Viral infection
b. Yeast infection
c. Streptococcal infection
d. Staphylococcal infection - A client has an Unna boot applied for treatment of a venous stasis
leg ulcer. The LPN/LVN notes that the client’s toes are mottled,