HESI PN COMPREHENSIVE EXIT EXAM

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HESI PN COMPREHENSIVE EXIT EXAM

VERSION 4

• A nurse in a LTC facility notices a client who has Alzheimer’s disease standing

at the exit door at the end of the hallway. The client appears to be anxious & agitated. What action should the nurse take?

ANS: Escort the client to a quiet area on the nursing unit.

• A client c Alzheimer experiences chronic confusion. Guiding the client to a

quiet, familiar area will help decrease agitation. They will be unable to follow instructions/commands.

• A nurse is assisting with the plan of care for a client who has a continent

urinary diversion. Which intervention should the nurse plan to implement to facilitate urinary elimination?

ANS: Use intermittent urinary catheterization for the client at regular

intervals.

• A continent urinary diversion contains valves that prevent urine from exiting

the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client’s pouch.

• A nurse is assisting with an education program about car restraint safety for

a group of parents. Which statement by the parent indicates an understanding of the instructions?

ANS: “My 12YO child should place the shoulder-lap seatbelt low across his

hips.”

• When a child is old enough to only use a shoulder-lap seatbelt, he should

place it low across his hips rather than over the abdomen to reduce risk for injury during motor vehicle crash.

• A nurse is reinforcing teaching about strategies to promote eating with a

client who has COPD. Which instructions should the nurse include in the teaching?

ANS: Drink high-protein and high-calorie nutritional supplements.

• The nurse should instruct the client to drink high-protein and high-calorie 1 / 2

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nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that leads to hypermetabolism and wasting of the client’s muscle mass.

• When removing PPE after direct care for a client who requires airborne &

contact precautions, which PPE is removed first?

ANS: Gloves

• The greatest risk is contamination from pathogens that might be present on

the PPE; therefore, the priority action for the AP is to remove the gloves, which are considered the most contaminated.

• A nurse is inspecting the skin of a newborn. Which finding should the nurse

report to the PCP?

ANS: Generalized Petechiae

• Petechiae are an expected finding over the presenting part of the newborn,

such as on the forehead in a brow presentation, & also anywhere on the head of infants who had a nuchal cord, w/c is an umbilical cord around the neck. However, petechiae all over the newborn’s body can indicate infection or decreased platelet count and should be reported to the provider.

• A nurse is contributing to a teaching plan for a group of male adolescents

about the A/E of anabolic steroid use. Which manifestations should the nurse include?

ANS: Reduced height potential

• Use of anabolic steroids in adolescence can lead to premature epiphyseal

closure, thus reducing full height potential. A/E includes: Liver disorders,

hyperlipidemia, breast enlargement, acne, and edema.

• A nurse is reinforcing teaching with an older adult client who has severe

L-sided HF. Which statement should the nurse make?

ANS: Rest for 15 minutes between activities.

• The nurse should instruct to increase his activity gradually & to rest for a

period of 15 min if he becomes tired. Clients who have HF should balance activity c rest to reduce cardiac workload.

• A nurse in a LTC facility is documenting the care of an older adult client.

Which information should be included in weekly nursing care summary?

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