l 2023 PN HESI EXIT EXAM VERSION 5/PN
HESI EXIT /HESIEXIT PN NEWEST EXAM
QUESTIONS AND CORRECT
ANSWERS|ALREADY GRADED A+
1. 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
2. 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
3. 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
4. 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. 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.
5. 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
• 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 of
an extremity that is being used to measure blood pressure and is caused by
hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented.
6. A 56-years-old man shares with the nurse that he is having difficulty making decision about
terminating 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 first
provide 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 are
important to him in the decision-making process.
7. A client is being discharged home after being treated for heart failure (HF). What instruction
should 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 daily
8. 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 ulcer
9. 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 techniques
10. A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum
potassium level 3.0 mEq/L. Which assessment is most important for the nurse to
obtain?
• Cardiac rhythm and heart rate.
• Daily intake of foods rich in potassium.
, • Hourly urinary output
• Thirst ad skin turgor.
11. The nurse note a depressed female client has been more withdrawn and non-communicative
during the past two weeks. Which intervention is most important to include in the updated
plan 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 focus
on non-threatening subjects can be an effective means of eliciting a response,
thereby decreasing isolation behaviors. There is not sufficient data to support the
effectiveness of A as an intervention for this client. Although B may be
indicated, nursing interventions can also be used to treat this client. C is too
threatening to this client.
12. A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel)
subcutaneously once weekly. The nurse should emphasize the importance of reporting
problem to the healthcare provider?
• Headache
• Joint stiffness
• Persistent fever
• Increase hunger and thirst
• Rationale: Enbrel decrease immune and inflammatory responses, increasing the
client’s risk of serious infection, so the client should be instructed to report a
persistent fever, or other signs of infection to the healthcare provider.
13. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment
finding 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 client
had over the previous 2 to 3 month, and level of 6.5 g/100 ml suggest that the
client
pg. 4
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