HESI Foundations Final Exam 2023 latest

HESI Foundations Final Exam 1. The practical nurse (PN) is providing skin care to an older male client who has the tendency to stay on his left side in a lying position. Which bony prominence should the PN identify as the site most likely to develop alterations in skin integrity? A. Ilium. Correct 2. 2.ID: 09 The practical nurse (PN) is preparing to give a complete bed bath to an unconscious client. After implementing standard precautions before the procedure, what action should the PN implement next? A. Wash each eye with a fresh area of a washcloth before washing the rest of the face. Correct 3. 3.ID: 41 When providing perineal care for an uncircumcised male client, the practical nurse (PN) should implement which action? A. Retract the foreskin before cleansing the glans and replace the foreskin after the procedure. Correct 4. 4.ID: 93 The healthcare provider prescribes a vest restraint for an older male resident in a long-term facility who frequently falls out of his wheelchair. Which action should the practical nurse (PN) implement? A. Remove device every 2 hours and change client’s position. Correct 5. 5.ID: 15 The healthcare provider prescribes wrist restraints for a client who is agitated and combative. Which action should the practical nurse (PN) implement? A. Check the client's skin color, warmth, and pulses distal to the restraining device. Correct 6. 6.ID: 83 A client who is placed in wrist protective devices begins to complain of pain and swelling in one hand. The practical nurse (PN) notes that both hands are cool and pale. What action should the PN implement? A. Remove both devices and notify the healthcare provider. Correct 7. 7.ID: 17 The practical nurse (PN) notifies the healthcare provider that a male client has become combative and needs a protective device to prevent injury to self and others. Which principle should the PN use when selecting a protective device? A. A protective device provides the least amount of immobilization. Correct 8. 8.ID: 99 The practical nurse (PN) hears an auscultatory gap in the Korotkoff sounds of an older client with hypertension. What action should the practical nurse (PN) implement when obtaining the client's blood pressure? A. Continue to listen for the next Korotkoff sound until the cuff is deflated. Correct 9. 9.ID: 97 The practical nurse (PN) obtains an irregular pulse rate of 102 beats/minute for a client with a history of cardiac disease. Which action is most important for the PN to implement? A. Listen to the apical rate for one full minute. Correct 10. 10.ID: 31 For several days after her husband's death, a client who is admitted with acute depression repeats over and over, "I should have made him go to the doctor when he said he didn't feel well." Which descriptor should the practical nurse use to document the client's feelings? A. Guilt. Correct 11. 11.ID: 01 Which client group is most likely to experience a therapeutic response from therapeutic touch? A. Clients with headaches. Correct 12. 12.ID: 11 An older client is receiving normal saline at 83 ml/hour per gravity. At the end-of-shift assessments, the practical nurse (PN) calculates the client's intake and output and determines that the infusion delivered 500 ml in the last hour. Which action should the PN take first? A. Auscultate the lungs for crackles. Correct 13. 13.ID: 69 Which action should the practical nurse (PN) implement to minimize the risk of hypernatremia for an older client? A. Offer fluids on a set schedule throughout the day. Correct 14. 14.ID: 19 A client's serum potassium level is 2.9 mEq/L. Which is the most important finding that the practical nurse (PN) should report to the charge nurse? A. Pulse rate weak and irregular. Correct 15. 15.ID: 45 An unlicensed assistive personnel (UAP) tells the practical nurse (PN) that another nurse on the unit is acting disrespectfully. What action should the PN implement? A. Tell the UAP to share feelings with the nurse. Correct 16. 16.ID: 07 The practical nurse (PN) is collecting data from clients' electronic medical records for the nurse manager's quality assurance review about documentation of client pain relief. What information should the PN include as the best measure of pain relief? A. Client pain intensity documented 1 hour after analgesia. Correct 17. 17.ID: 49 The practical nurse (PN) is preparing to reinforce information with a client who has chronic pain. Which learning objective should the PN review? A. Recalls two nonpharmacological interventions used to relieve pain. Correct 18. 18.ID: 11 The practical nurse (PN) is calculating an 8-hour intake for a postoperative client. Based on the client's bedside record, how many ml of intake should the PN enter in the client's electronic record? (Enter numeric value only.) One cup of coffee One 8-ounce glass of iced tea One 6-ounce dish of flavored gelatin One-half cup of chicken broth Correct Correct Responses A. 780 2 ....19.ID: 55 The family of a male client with terminal cancer decides to not tell the client about his prognosis. The client has asked the practical nurse (PN) several times if he is dying. What action should the PN implement? A. Discuss the client's frequent questions with family and healthcare provider. Correct B. ..20.ID: 07 The practical nurse (PN) is reviewing discharge information with a client who is positive for HIV. Which action should the PN reinforce with the client to help prevent transmission of HIV? A. Disinfect areas contaminated with body fluids using 1:10 bleach solution. Correct C. 21.ID: 91 What findings should the practical nurse (PN) document to describe infiltration at a client's intravenous (IV) site? A. Edema and cool skin at insertion site. Correct D. 22.ID: 79 The practical nurse (PN) is administering eye drops to a client with glaucoma. Which technique should the PN implement to ensure the eyes drops are effectively absorbed topically? A. Tell the client to move closed eyes from side to side. Correct E. 23.ID: 09 The practical nurse (PN) is assigned the PM care of six clients on a medical surgical unit whose morning laboratory results are not available. What action should the PN take? A. Call the laboratory to ask if the clients' test results are ready. Correct F. 24.ID: 45 The practical nurse is administering otic drops to an adult client with otitis externa. Which action describes the correct administration technique? A. Pull the pinna of the ear up and out. Correct G. 25.ID: 03 The practical nurse (PN) uses the SBAR format to report an acute client situation to the healthcare provider. Which information is the correct understanding of this method? A. The "R" stands for recommendation and suggests an action for the healthcare provider. Correct H. 26.ID: 65 A client is admitted with bacterial meningitis. Which intervention is most important for the practical nurse (PN)? A. Implement droplet precautions. Correct I. 27.ID: 25 A male client with coffee ground emesis is admitted with a hemoglobin of 10.2 grams that is now 7.5 grams/dl since admission. The client's blood is typed and crossmatched for 2 units of blood, and the healthcare provider prescribes STAT administration of one unit. The client indicates to the practical nurse (PN) that he wants to shower first. Which intervention should the PN implement? A. Explain the need for starting the transfusion immediately. Correct J. 28.ID: 43 The practical nurse (PN) is reinforcing self-care with a male client who is being discharged with an ileostomy. Which client behavior best indicates to the PN that he understands ileostomy care? Empties the ileostomy appliance bag when it is about one-third full. Correct K. 29.ID: 23 The practical nurse (PN) is documenting the administration of a client's medication. Which entry by the PN complies with The Joint Commission (TJC) guidelines for use of abbreviations? A. Doses of clonidine 0.15 mg given AC BID. Correct L. 30.ID: 49 The practical nurse (PN) is assisting the nurse in the administration of a unit of blood to a client with AB positive blood type. Which finding should the PN identify as a policy standard that should be addressed first? A. The client does not have an identification bracelet. Correct M. 31.ID: 89 When determining if the client is compliant with a prescribed medication regimen, which question is best for the practical nurse (PN) to ask? A. "When and where do you take this pill at home?" Correct N. 32.ID: 27 When should the practical nurse (PN) reinforce teaching to a client about a daily surgical dressing change? A. During the next dressing change. Correct O. 33.ID: 37 A male client who walks in the clinic begins talking to the practical nurse (PN) with slurred speech. Which action should the PN implement first? A. Ask the client how he is feeling today. Correct P. 34.ID: 16 The practical nurse (PN) is planning morning care for a client with gastrointestinal bleeding and a hemoglobin level of 8.1 grams/dl who is scheduled to receive a unit of packed red blood cells (PRBC's). Which action should the practical nurse (PN) take? A. Initiate serial vital signs before and during the transfusion. Correct Q. 35.ID: 87 Which intervention is most important for the practical nurse (PN) to implement to decrease the number of falls for clients in a long-term care facility? A. Inquire about the client's level of pain. B. Ask about the need to use bathroom. Correct R. 36.ID: 59 The practical nurse (PN) is caring for a client who begins to vomit copious amounts of blood. What action should the PN do first? A. Use a Yankauer-tip device for oropharyngeal suction. Correct S. 37.ID: 21 The practical nurse (PN) is giving iron dextran (Imferon) 250 mg IM using the Z-track method to a client with anemia. Which needle should the PN select for this injection? A. 2-inch, 19 gauge needle. Correct T. 38.ID: 55 The practical nurse (PN) is obtaining a blood specimen from a client's peripherally inserted central catheter (PICC). What action should the PN to implement first? A. Discard first 5 ml of blood sample. Correct U. 39.ID: 39 A client who has a tunneled Hickman catheter for hemodialysis receives a prescription for IV antibiotics. Which action should the practical nurse take? A. Utilize a peripheral IV access to administer IV antibiotics. Correct V. 40.ID: 53 The practical nurse (PN) finds an older female client lying on the floor. What action should the PN take first? A. Obtain the client's vital signs. Correct W. 41.ID: 89 The practical nurse (PN) is preparing to change the abdominal dressing for a client who had abdominal surgery yesterday. When should the PN reinforce teaching about the client's dressing change? A. During this dressing change. Correct X. 42.ID: 77 A client presents to the emergent care center reporting chest pain and feeling "lightheaded," as if he is "going to faint." What is the most important action the practical nurse (PN) should implement? A. Place client in a chair or upright on a stretcher. Correct Y. 43.ID: 33 The practical nurse (PN) is obtaining blood specimens from a client. After inserting the needle into the arm, the client screams and reports an electric "shooting" pain in the arm. What action should the PN implement? A. Withdraw the needle from the arm. Correct Z. 44.ID: 37 A client with Clostridium difficile is placed on isolation precautions. Which transmission-based precaution should the practical nurse implement? A. Wear gown and gloves when rendering direct care. Correct AA.45.ID: 14 The practical nurse (PN) stops to help at a serious motor vehicle collision site and applies pressure to one of the victim's neck that is spurting blood. The client subsequently dies. Which legal concept applies to the PN's actions? A. Good Samaritan. Correct BB. 46.ID: 29 A client with a forearm laceration arrives in the clinic applying direct pressure with a clean washcloth. The practical nurse (PN) notes that the washcloth is saturated with blood. What action should the PN implement? A. Apply digital pressure to arm above the injury. Correct CC. 47.ID: 57 The practical nurse (PN) is caring for an older client who is receiving oxygen 4 L per nasal cannula. Which finding indicates a therapeutic response? A. Client oriented to time and place. Correct DD.48.ID: 41 The practical nurse (PN) is reviewing the electronic medication administration record (MAR) for a client who receives warfarin (Coumadin) daily. A notation on the MAR for yesterday is marked "hold" for the daily Coumadin dose and no other directions are noted for today's dose. What action should the PN take? A. Check the prescription. Correct EE. 49.ID: 21 An older client arrives at the outpatient clinic complaining of burning and severe right-sided "chest pain." The practical nurse (PN) observes vesicular eruptions in a line across the anterior and posterior chest wall. What action should the PN implement? A. Wear gloves during palpation. Correct FF. 50.ID: 53 Which intervention should the practical nurse (PN) implement for a client who is scheduled for a lumbar puncture? A. Ensure the client's bed is positioned flat. Correct