SCIENCE AB Fundamentals Hesi Practice Questions

SCIENCE AB Fundamentals Hesi Practice Questions Question 1 of 50 Following an open reduction of a fractured femur, a client is placed in skeletal traction. Based on the nursing diagnosis of "Potential impairment of skin integrity related to immobility," which nursing intervention should the practical nurse (PN) implement? - Lubricate the hands, slide them under the client, and give back care. Rationale: Back care provides the best method for solving immobility problems, such as skin breakdown, when the client is in traction. Question 2 of 50 The practical nurse (PN) determines that a client's radial pulse is irregular. What action should the PN take next? - Take an apical pulse for 1 minute to verify irregularity Rationale: Too much digital pressure can obliterate radial pulsations, especially if the client has a weak pulse, so a different assessment technique is indicated. Auscultation of the apical heartbeat for 1 minute is the most accurate method of evaluating cardiac rhythm and verifying the irregularity. Question 3 of 50 Before performing a fecal occult blood test or guaiac test on a stool specimen, the practical nurse (PN) should ask the client about the regular use of which vitamin? - C Rationale: The guaiac test measures microscopic amounts of blood in feces. A false-positive result can occur from the regular use of vitamin C. Question 4 of 50 Before performing a fecal occult blood test or guaiac test on a stool specimen, the practical nurse (PN) should ask the client about the regular use of which vitamin? - C Rationale: The guaiac test measures microscopic amounts of blood in feces. A false-positive result can occur from the regular use of vitamin C. Question 5 of 50 The practical nurse (PN) is counting a client's respiratory rate. During a 30-second interval, the PN counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the PN counts eight respirations. What respiratory rate should the PN document? - 16 breaths/min Rationale: The most accurate respiratory rate is the second count obtained by the PN, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Question 6 of 50 Which nursing diagnosis has the highest priority that the practical nurse (PN) should identify when planning care for a client with an indwelling urinary catheter? - High risk for infection Rationale: Indwelling urinary catheters are a high source of infection. Question 7 of 50 The practical nurse (PN) is applying the finger probe for continuous pulse oximetry on a client. Which actions should help prevent skin irritation or breakdown? (Select all that apply.) -Rotate the probe location site every 4 to 8 hour - Cleanse with soap and water as needed - Secure with gauze if client has allergy to adhesives Rationale: Site rotation, skin cleansing, and avoidance of adhesives for allergies should help prevent skin irritation or breakdown. Question 8 of 50 An elderly client calls the clinic reporting weakness and dizziness. Further assessment by the practical nurse (PN) indicates that the client self-administered an enema of 3 liters of tap water to relieve constipation. What is the most likely cause of the client's symptoms? - Water intoxication Rationale: Tap water is a hypotonic fluid, which can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication. This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. Question 9 of 50 To administer a saline enema to a client, the practical nurse (PN) inserts the enema tubing 3 inches into the client's rectum and elevates the saline container 6 inches above the client's body. After the PN opens the clamp, the saline solution does not infuse. What is the best action for the PN to take? - Raise the saline container 6 more inches above the body Rationale: The saline flows by gravity and should be held about 12 inches above the body. Question 10 of 50 The practical nurse (PN) is observing a new unlicensed assistive personnel (UAP) perform indwelling catheter care for a female client who is incontinent of feces. What action should the PN suggest the UAP to change? - Frequently rinses the washcloth used to clean the perineum Rationale: Even though the washcloth is rinsed frequently, it remains contaminated with fecal materials, and the PN should recommend the use of disposable wipes or separate washcloths, which are less likely to bring fecal flora to the urethral opening. Question 11 of 50 A client receives a prescription for a 5-mg dose of a drug. The oral preparation of this drug is available as 3 mg/capsule. Which intervention should the practical nurse (PN) implement? - Call the health care provider about the prescribed dose Rationale: Because this drug is only available in oral form as capsules containing 3 mg, the health care provider should be contacted because the prescribed dose cannot be administered. Question 12 of 50 A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and tachypnea. What action should the practical nurse (PN) take first? - Raise the head of the bed Rationale: Raising the head of the bed facilitates respiratory functioning. The first action is that client should be placed in a semi-Fowler or Fowler position. Although tracheal deviation can occur with a tension pneumothorax, the client should be placed in an upright position in the bed before further assessment is obtained. Question 13 of 50 The practical nurse (PN) is administering medications to a client via a nasogastric tube. The 0900 medications include a sustained-release spansule. Which action should the PN take when administering the sustained-release drug via the nasogastric tube (NGT)? - Consult the health care provider for a different drug form that can be crushed Rationale: Administration of sustained-release (SR) spansules is contraindicated via nasogastric tube so the PN would have to consult the health care provider for a different drug form that can be crushed. Question 14 of 50 A mother calls the clinic and states that she does not know how many teaspoons of medication to give her child because the directions on the bottle read, "Give 15 mL." How many teaspoons should the practical nurse (PN) instruct the mother to administer to her child? (Fill in the blank. Type in numbers only as your answer and round to nearest whole number). -1 teaspoons Rationale: 5 mL = 1 teaspoon. 5 × 3 = 15 mL = 3 teaspoons Question 15 of 50 The practical nurse (PN) is assisting a client to ambulate with a cane. Arrange the steps in ascending order from the first task to the last task. All options must be used. -Explain the procedure to the client - Apply a gait belt to the client - Have the client hold the cane in the hand of the unaffected extremity - Have the client advance the cane and the affected leg - Have the client lean on cane while moving unaffected leg forward Rationale: First, the PN should explain the procedure to the client; second, a gait belt should be applied to provide improved safety for both the PN and the client during ambulation; third, the cane should be held in the unaffected extremity; fourth, the cane and the affected leg should be advanced; and fifth, the client should lean on the cane while moving the unaffected leg forward. Question 16 of 50 A client's plan of care includes a nursing diagnosis of "Altered sleep patterns related to nocturia." Which client information is important for the practical nurse (PN) to provide? - Decrease your intake of fluids after the evening meal Rationale: Decreasing intake of fluids during the evening is helpful to decrease nocturia Question 17 of 50 The practical nurse (PN) is assisting with bathing an independent adult client who has a plaster cast on the right forearm. Which action should the PN implement to encourage self-care by the client? - Provide back care and foot care as needed Rationale: The PN should provide back care, foot care, and other assistance as needed by the client, but the client's independence should be encouraged and his privacy respected. Question 18 of 50 While morning care is being provided, a client becomes restless, agitated, and confused. The client's heart rate is elevated, and respiratory rate is 24 breaths/min. Which additional finding should the practical nurse (PN) identify as an early sign of hypoxia? - Elevated blood pressure Rationale: The blood pressure becomes elevated during the early stages of hypoxia in an effort to increase perfusion to distal tissues. Respiratory changes related to hypoxia are increased rate and depth of respiration. Question 19 of 50 An elderly client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the practical nurse (PN) to consider before assisting this client? - Blood pressure of 86/54 mm Hg Rationale: Hypotension places the client at risk for falls because it can cause dizziness. To ensure client safety, it is most important for the PN to be aware of the client's low blood pressure before transfer. Question 20 of 50 A representative of the hospital's accrediting agency is performing an on-site visit at the hospital and asks to see the nurses' notes from a client's medical record. What action should the practical nurse (PN) take? - Provide the agency representative with the information from the client's medical record Rationale: A hospital's accreditation agency randomly selects clients and reviews the nursing care documentation to evaluate the standard of care being provided by the hospital. The practical nurse (PN) can provide the agency representative with the requested information. Question 21 of 50 The practical nurse (PN) enters a client's room and finds the client on the floor after a fall. How should the PN communicate this situation to the risk management team? - Submit a completed incident report describing the situation to the unit manager Rationale: Incident reports must be completed by the PN who has first-hand knowledge of the facts of the situation. Question 22 of 50 Which instruction should the practical nurse (PN) provide to a client whose vision is being tested with a Snellen chart? - Cover one eye while reading the chart with the other Rationale: Each eye should be tested separately because visual acuity can vary from one eye to the other. The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read. Question 23 of 50 During the initial morning assessment, a client denies dysuria but reports dark amber urine. Which intervention should the practical nurse (PN) implement? - Encourage additional oral intake of juices and water Rationale: Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake. Question 24 of 50 When performing sterile wound care in the acute care setting, the practical nurse (PN) obtains a bottle of normal saline from the bedside table that is labeled opened and is dated 48 hours before the current date. What is the best action for the PN to take? - Discard the saline solution and obtain a new and unopened bottle Rationale: Solutions labeled within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Question 25 of 50 The practical nurse (PN) is performing nasotracheal suctioning. After the client's trachea is suctioned for 15 seconds, large amounts of thick yellow secretions return. What action should the PN implement next? - Reoxygenate the client before attempting to suction again Rationale: Suctioning should not be continued for longer than 10 to 15 seconds because the client's oxygenation is compromised during this time. Question 26 of 50 The practical nurse (PN) is assessing the orientation of an elderly client. The client is unable to remember the year and reports being lost and unfamiliar with the surroundings. What documentation is the most accurate for the PN to make? - Is disoriented to time and place Rationale: The client is exhibiting disorientation. Question 27 of 50 A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the practical nurse (PN)? - Purulent sputum Rationale: Steroids cause immunosuppression, and purulent sputum is an indication of infection, so this symptom is of greatest concern. Question 28 of 50 The practical nurse (PN) is instructing a client in the proper use of a metered-dose inhaler. Which instructions should the PN reinforce to the client to ensure the optimal benefits from the drug? - Compress the inhaler while slowly breathing in through the mouth Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. Question 29 of 50 The practical nurse (PN) is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. What action should the PN take next? - Document that the client responded to a painful stimulus Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Question 30 of 50 The practical nurse (PN) is preparing to administer a prescribed dose of digoxin 125 mcg PO. The medication available is 0.25 mg per tablet. How many tablets should the PN administer? (Fill in the blank. Type in numbers only and round to the nearest tenth.) - 0.5 Rationale: 125 mcg × 1 mg/1000 mcg × 1 tablet/0.25 mg = 0.5 tablet Question 31 of 50 Which action is most important for the practical nurse (PN) to implement when donning sterile gloves? - Keep gloved hands above the elbows Rationale: Gloved hands held below waist level are considered unsterile Question 32 of 50 An elderly client who attends an adult day care program and is wheelchair-mobile has redness in the sacral. Which information is most important for the practical nurse (PN) to provide? - Change positions in the chair at least every hour Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers Question 33 of 50 Which serum laboratory value should the practical nurse (PN) monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? - Sodium Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning. Question 34 of 50 The practical nurse (PN) reinforces information with a client about portion control and diet management. Which portion description indicates that the client understands the instructions? - Four small cookies are about the size of four poker chips Rationale: Four small cookies are about the size of four poker chips Question 35 of 50 The practical nurse (PN) is administering a rectal suppository to a client. What action should be implemented to prevent discomfort during administration? - Allow the suppository soften before insertion Rationale: Allowing the suppository to soften slightly before insertion will decrease the possibility of causing trauma or discomfort to the client. Question 36 of 50 The HIV unit nursing team, composed of the registered nurse (RN) case manager, staff RNs, and staff practical nurses (PNs), is meeting to discuss a client who has developed anorexia related to HIV medications. The client has lost 15 pounds in the previous 2 months. Which action should the team implement to continue the nursing process? - Collaborate with the client to set goals Rationale: The client has been assessed and the cause determined, so the next step in the nursing process is to collaborate with the client to set goals. When clients are included in the nursing process, the plan of care becomes more client-focused Question 37 of 50 Which intervention is most important for the practical nurse (PN) to implement for a client who is experiencing urinary retention? - Assess for bladder distention Rationale: Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention therefore it is vital to assess for bladder distention. Question 38 of 50 Which client finding requires further action by the practical nurse (PN)? - The drainage tube of an indwelling catheter is looped below the client's bladder Rationale: Urine collecting in a loop of tubing that is dependent will not drain properly and places the client at risk for infection, so the (PN) should reposition the urinary drainage tube to eliminate looping below the bladder. Question 39 of 50 The practical nurse (PN) is assessing a client's 2 days status/posthip replacement surgery. In assessing the client's vital signs, which finding requires the most immediate action by the PN? - Hyperthermia Rationale: Hyperthermia, an elevated body temperature, requires the most immediate action to determine the cause of the fever and contact the health care provider Question 40 of 50 Which action should the practical nurse (PN) implement to ensure that eye ointment is distributed evenly across the eye and lid margin? - Instill the ointment along the lower inner edge of the eyelid from the inner to the outer canthus Rationale: To instill eye ointment, the practical nurse (PN) would hold the ointment applicator above the lower lid margin and apply a thin stream of ointment along the inner edge of the lower eyelid on the conjunctiva from the inner canthus to the outer canthus. Question 41 of 50 The practical nurse (PN) is caring for a dyspneic client whose oxygen saturation rate is currently 95%. What position is best for this client? - Fowler's with both legs supported Rationale: In the Fowler position, the head is elevated 45 degrees, and the individual's knees are slightly flexed, which promotes maximum lung expansion and tracheal alignment. Even though the client's oxygen saturation rate is within normal limits (WNL), this client is having trouble breathing. Sitting up, so that the lungs can fully expand and the trachea is aligned, is usually helpful in promoting breathing. Question 42 of 50 While performing colostomy care, the practical nurse (PN) observes skin irritation around the stomal site. What action should the PN take when reapplying the colostomy bag? -Ensure that the hydrocolloidal stomal wafer covers the peristomal skin Rationale: Hydrocolloid stomal wafers should be measured precisely to ensure peristomal skin coverage and protection from irritation and breakdown. The stomal site should be cleansed gently with a moist, soft cloth and mild soap and another bag applied to prevent skin contact with fecal drainage. Question 43 of 50 The practical nurse (PN) is assessing several clients before surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? - Taking anticoagulants for the past year Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for developing surgical complications. The health care provider should be informed that the client is taking such drugs. Question 44 of 50 The practical nurse (PN) is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later, the client reports that the insomnia continues despite following the same routine every night. What action should the PN take first? - Ask the client to describe the current routine practiced by the client Rationale: The PN should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information. Question 45 of 50 A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement should the practical nurse (PN) identify that best demonstrates the client's readiness to manage his/her wound care after discharge? - The client demonstrates the wound care procedure correctly Rationale: A return demonstration of a procedure provides an objective assessment of the client's ability to perform a task. Question 46 of 50 Which instruction is most important for the practical nurse (PN) to provide a client before the client leaves the unit to have magnetic resonance imaging (MRI) performed? -Remove all metal objects from the body Rationale: Dental bridges, hair clips, belts, credit cards, jewelry, and patches with a foil backing, such as nicotine patches, can create burns on the client and cause artifacts on the scan, so removing all metal objects from the body is the most important instruction to provide the client before an MRI. Question 47 of 50 The practical nurse (PN) obtains lying and standing blood pressure measurements for a client who complains of dizziness upon standing up from the computer at work. The PN determines that systolic pressure decreases 24 mm Hg when standing. What intervention is most important for the PN to implement? - Encourage the client to flex both feet before rising slowly Rationale: Orthostatic hypotension is a sudden fall in blood pressure, usually greater than 20/10 mm Hg, that occurs when suddenly rising from a sitting or lying position to a standing position. Stimulates skeletal muscle contraction that promotes venous return and helps prevent syncope or injury. Question 48 of 50 A client has an oral intake during the previous 8 hours of the following: 2 cups coffee, 240 mL milk, ¾ cup applesauce, 1 liter water, 6 ounces fruit juice, and 3 ounces pudding. How many milliliters will the practical nurse (PN) record as the total 8-hour oral intake? (Fill in the blank. Type in numbers only as your answer and round to the nearest whole number.) -1900 Rationale: Intake includes all liquid taken by mouth, any foods that turn to liquid at room temperature (e.g., gelatin, ice, ice cream), and intravenous fluids or tube feedings. Applesauce and pudding are not included as fluids because these items do not turn to liquid at room temperature. Fluids recorded in cups, liters, or ounces need to be converted to milliliters. Conversions needed to calculate the total intake include the following: 1 cup = 240 mL; 1 ounce = 30 mL; and 1 liter = 1000 mL. 480 mL + 240 mL + 1000 mL + 180 mL = 1900 mL Question 49 of 50 When reading a prescription, what should the practical nurse (PN) verify in addition to the "five rights" of medication administration? - Prescriber's signature Rationale: A legal medication prescription must include the prescriber's signature. Question 50 of 50 The spouse of a client with terminal cancer provided the practical nurse (PN) with a copy of the client's living will. What action should the PN take? - Notify the health care provider of the client's wishes Rationale: The health care provider needs to be informed of the clientʼs wishes and a prescription written to specify how the staff should respond to medical emergencies. A copy should be placed on the chart, but it does not need to be a certified copy. A living will does not necessarily indicate DNR status. The client and the clientʼs family should be informed about palliative care, but a meeting with the team should be facilitated only at their request.