HESI Comprehension Practice Test - Questions, Answers and Rationales

HESI Comprehension Practice Test - Questions, Answers and Rationales The practical nurse (PN) is planning care for a client who is admitted with a Braden scale score of 2 in each of the six subcategories. Toward which goal in the client's care should the PN focus nursing interventions? A. Prevention of pressure ulcers. B. Improved hygienic measures. C. Temperature within normal limits. D. Absence of signs of infection. The Braden scale measures degrees of sensory perception, moisture, activity, mobility, nutrition, friction, and shear that indicate a client's risk for skin breakdown. A client with acute pancreatitis has a low serum calcium level. The practical nurse (PN) observes that the lips, nose, and side of the face contract after the client's face is cleansed with a cloth. Which documentation describes these findings? A. Bell's palsy noted. B. Tic douloureux noted. C. Chvostek's sign noted. D. Trousseau's sign noted. Chvostek's sign indicating low serum calcium is manifested by spasms of the muscles innervated by the facial nerve, which is elicited by tapping the client's face lightly below the temple. The unlicensed assistive personnel (UAP) asks the practical nurse (PN) how to position a client for tube feedings? A. Elevate the head of the bed. B. Use a Sims' position. C. Place in a left lateral position. D. Allow a position of comfort. The head should be elevated 45 degrees before and one hour after feeding to reduce the possibility of aspiration. A 34-year-old male client who is admitted to the mental health unit for paranoia is responding to antipsychotic medications. After the healthcare team decides to discharge the client, he tells the practical nurse (PN) that his wife is unfaithful and he plans to get her for this. How should the PN respond? A. Report to the team that the client's wife should be informed. B. Ask the client if he will comply with the mandatory day hospital visits. C. Tell the client to discuss his medication dose with his healthcare provider. D. Explain the consequences if he carries out his threats to his wife. Mental healthcare member has the responsibility of Duty to Warn and report any intended, identified victim of possible future harm by a client. The practical nurse (PN) is caring for a client in hospice who is comatose and needs vigorous suctioning. The PN is conflicted about implementing the needed care. What ethical action should the PN do first? A. Ask for a different client care assignment. B. Refer to the client's living will documentation. C. Review the nursing code of ethics for guidance. D. Speak with the unit supervisor about the problem. The first step in processing an ethical decision is clarification of one's personal values by discussing the issue with other nurses, the unit supervisor, or the ethics committee. The practical nurse (PN) is talking with an adult male client who says that he is satisfied with how he has lived his life. According to Erikson's staging theory, this client is in which stage? A. Integrity versus despair. B. Intimacy versus isolation. C. Identity versus role confusion. D. Generativity versus stagnation. According to Erikson's Ego theory and developmental model, an older adult who reviews one's life experiences with a sense of satisfaction and is at peace with inevitable death is in the stage of integrity versus despair. The practical nurse (PN) is assisting an adult female client with perineal care. Which position should the PN assist the client to take? A. Prone. B. Supine. C. Side-lying D. Dorsal recumbent. To perform female perineal care, a client should be assisted to the dorsal recumbent position, which provides visualization, comfort, and medical aseptic technique. A client with hypothyroidism receives a prescription for thyroid hormone replacement. Which sign(s) of overdose should practical nurse (PN) reinforce with the client? (Select all that apply.) A. Weight gain. B. Ataxia. C. Bradycardia. D. Nervousness. E. Irritability. F. Difficulty sleeping. An overdose of thyroid hormone replacement mimics the signs and symptoms of hyperthyroidism, which include nervousness, irritability, and insomnia. What therapeutic response should the PN monitor for in a client who is taking medications for tuberculosis? A. Cessation of a chronic cough. B. Tolerance to medication regime. C. Negative purified protein derivative (PPD) skin test. D. Negative sputum cultures and chest x-ray. Therapeutic effectiveness of antitubercular drugs is supported by clinical findings indicating negative sputum cultures for the acid fast bacilli and improved chest radiographs. An unlicensed assistive personnel (UAP) reports a blood pressure (BP) reading of 148/88 for a 10 year-old child who is above the 95th percentile on the growth chart. What intervention should the practical nurse (PN) implement? A. Check the size of the blood pressure cuff used. B. Instruct the UAP to repeat the BP measurement. C. Ask about the child's activity prior to the measurement. D. Review the child's history for evidence of renal disease. The size of a BP cuff should be checked because a cuff that is too small for a child above the 95th percentile is mostly likely to result in a falsely elevated reading. A client who delivered a 7 pound 8 ounce infant 3 hours ago has a soft, boggy uterus located above the umbilicus. What action should the practical nurse implement next? A. Perform fundal massage. B. Notify the charge nurse. C. Obtain a blood pressure. D. Initiate perineal pad count. A soft, boggy uterus places the client at increased risk for postpartum hemorrhage, so the PN should perform fundal massage to contract the uterus.