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?
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.
, HESI PN EXIT EXAM V3 100 QUESTIONS
AND ANSWER(S)ALL ANSWERS 100% CORRECT LATEST
UPDATE 2021/2022 GUARANTEED SUCCESS RATED A+
A client with a history of dementia has become increasingly confused at night
and is picking at an abdominal surgical dressing and the tape securing the
intravenous (IV) line. The abdominal dressing is no longer occlusive, and the
IV insertion site is pink. What intervention should the nurse implement?
• Replace the IV site with a smaller gauge.
• Redress the abdominal incision
• Leave the lights on in the room at night.
• Apply soft bilateral wrist restraints.
• Rationale: The abdominal incision should be redressed using aseptic-
techniques. The IV site should be assessed to ensure that it has not
been dislodged and a dressing reapplied, if need it. Leaving the light
on at night may interfere with the client’s sleep and increase
confusion. Restraints are not indicated and should only be used as a
last resort to keep client from self-harm.
An adult male client is admitted to the emergency room following an
automobile collision in which he sustained a head injury. What assessment
data would provide the earliest that the client is experiencing increased
intracranial pressure (ICP)?
• Rationale: Lethargy is the earliest sign of ICP along with slowing of
speech and response to verbal commands. The most important
indicator of increase ICP is the client’s level or responsiveness or
consciousness. B and C are very late signs of ICP.
In preparing a diabetes education program, which goal should the nurse
identify as the primary emphasis for a class on diabetes self-
management?
• Prepare the client to independently treat their disease process
• Reduce healthcare costs related to diabetic complications
• Enable clients to become active participating in controlling
the disease process
• Increase client’s knowledge of the diabetic disease process and
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ACADEMICNURSING001. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $25.98. You're not tied to anything after your purchase.
