HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWER(S) UPDATED WITH THE CORRECT ANSWERS HIGHLIGHTED
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HESI PN EXIT EXAM V3 110 QUESTIONS AND ANSWER(S) UPDATED WITH THE CORRECT ANSWERS HIGHLIGHTED.
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• HESI PN EXIT EXAM V3 110 QUESTIONS
• AND ANSWER(S)
301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103....
hesi pn exit exam v3 110 questions and answers updated with the correct answers highlighted
hesi pn exit exam v3 110 questions
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HESI PN EXIT EXAM V3 110 QUESTIONS AND
ANSWER(S) UPDATED WITH THE CORRECT
ANSWERS HIGHLIGHTED.
HESI PN EXIT EXAM V3 110 QUESTIONS
AND ANSWER(S)
301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes,
flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration
of 156 mEq/L. What physiologic mechanism contributes to this finding? Correct Answer: Insensible loss
of body fluids contributes to the hemoconcentration of serum solutes.
Rationale: Fever causes insensible fluid loss, which contribute to fluid volume and results in
hemoconcentration of sodium (serum sodium greater than 150 mEq/L). Dehydration, which is
manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids
and electrolytes with IV fluids that contain varying concentration of sodium chloride. Although other
options are consistent with fluid volume deficit, the physiologic response of hypernatremia is explained
by hem concentration.
302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is
working with a register nurse (RN) Correct Answer: Prepare a woman for a bone density screening.
Rationale: A bone density screening is a fast, noninvasive screening test for osteoporosis that can be
explained by the PN. There is no additional preparation needed (A) required a high level of
communication skill to provide teaching and address the client's fear. (B) Requires a higher level of client
teaching skill than responding to one client. (D) Requires higher level of knowledge and expertise to
provide needed teaching regarding this complex topic.
303. An adult client present to the clinic with large draining ulcers on both lower legs that are
characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which
action should the nurse take? Correct Answer: Send family to the waiting area while the client's history
is taking.
Rationale: To protect the client privacy, the family member should be asked to wait outside while the
client's history is take. Gloves should be worn when touching the client's body fluids if the client is HIV
positive and these lesion are actually Kaposi sarcoma lesion. HIV testing cannot legally be done without
the client explicit permission. A further assessment can be implemented after the family left the room.
304. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The
client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new
business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which
nursing problem has the greatest priority? Correct Answer: Imbalance nutrition.
Rationale: The client's nutritional status has the highest priority at this time, and finger foods are often
provided, so the client who is on the maniac phase of bipolar disease can receive adequate nutrition.
,Other options are nursing problems that should also be addresses with the client's plan of care, but at
this stage in the client's treatment, adequate nutrition is a priority.
305. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which
instruction is most important to include in this plan? Correct Answer: Avoid crowds for first two months
after surgery.
Rationale: Cyclosporine immunosuppression therapy is vital in the success of liver transplantation and
can increase the risk for infection, which is critical in the first two months after surgery. Fever is often.
306. The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed
for problems associated with chronic hypoxia? Correct Answer:
307. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns
to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%.
Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which
intervention the nurse implement? Correct Answer: Assess compliance with routine prescriptions.
Rationale: Fluid retention may be a sign that the client is not taking the medication as prescribed or that
the prescriptions may need adjustment to manage cardiac function post-PTCA (normal ejection fraction
range is 50 to 75%).
308. The RN is assigned to care for four surgical clients. After receiving report, which client should the
nurse see first? The client who is Correct Answer: Three days postoperative colon resection receiving
transfusion of packed RBCs.
309. The nurse is preparing an older client for discharge following cataract extraction. Which instruction
should be include in the discharge teaching? Correct Answer: Avoid straining at stool, bending, or lifting
heavy objects.
Rationale: after cataract surgery, the client should avoid activities which increase pressure and place
strain on the suture line.
310. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6
hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of
potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is
required, round to the nearest tenth.) Correct Answer: 12.5.
Rationale: Using the formula D / H X Q: 25 mEq / 10 mEq x 5ml ꞊12.5ml
311. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has
finally found a comfortable position. What action should the nurse take? Correct Answer: Place a wedge
under the client's right hip.
Rationale: Hypotension from pressure on the vena cava is a risk for the full-term client. Placing a wedge
under the right hip will relieve pressure on the vena cava. Other options will either not relieve pressure
on the vena cava or would not allow the client the remaining her position of choice.
312. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath,
anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with
audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5
ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at
, mcg/kg/minute per infusion pump. With intervention should the nurse implement? Correct Answer:
Titrate the dopamine infusion to raise the BP.
Rationale: the client is experiencing cardiogenic shock and requires titration per protocol of the
vasoactive secondary infusion, dopamine, to increase the blood pressure. Low hourly urine output is due
to shock and does not indicate a need for catheter irrigation. Pacing is not indicated based on the
client's capillary blood glucose should be monitored, but is not directly indicated at this time.
313. The nurse ends the assessment of a client by performing a mental status exam. Which statement
correctly describes the purpose of the mental status exam? Correct Answer: Evaluate the client's mood,
cognition and orientation.
Rational: the mental status exam assesses the client for abnormalities in cognitive functioning; potential
thought processes, mood and reasoning, the other options listed are all components of the client's
psychosocial assessment.
314. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client
has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently
142/89. Which interventions should the nurse implement? (Select all that apply) Correct Answer:
Administer a daily dose of lisinopril as scheduled.
Provide a PRN dose of acetaminophen for headache.
Rational: the client' routinely scheduled medication, lisinopril, is an antihypertensive medication and
should be administered as scheduled to maintain the client's blood pressure. A PRN dose of
acetaminophen should be given for the client's headache. The other options are not indicated for this
situation.
315. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should
eat? (Select all that apply) Correct Answer: Pasta, noodles, rice.
Egg, tofu, ground meat.
Mashed, potatoes, pudding, milk.
Rational: a client's postoperative diet is commonly progressed as tolerated. A soft diet includes foods
that are mechanically soft in texture (pasta, egg, ground meat, potatoes, and pudding. High fiber foods
that require thorough chewing and gas forming foods, such as cruciferous vegetables and fresh fruits
with skin, grains and seeds are omitted.
316. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L)
for discharge from the hospital. When teaching the parents about home phototherapy, which
instruction should the nurse include in the discharge teaching plan? Correct Answer: Reposition the
infant every 2 hours.
Rational: An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every
two hours. The position changes ensure that the phototherapy lights reach all of the body surface areas.
Bathing, feedings, and diaper changes are ways for the parents to bond with the infant, and can occur
away from the treatment. Feedings need to occur more frequently than every 4 hours to prevent
dehydration. The infant should wear only a diaper so that the skin is exposed to the phototherapy.
317. When planning care for a client with acute pancreatitis, which nursing intervention has the highest
priority? Correct Answer: Withhold food and fluid intake.
Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that
causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in
auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused
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