D&D HESI PN Exam Review
A client returns to the postoperative unit following an open reduction and internal fixation of a
hip fx. the PN applies the prescribed sequential compression device (SCD) to both lower
extremities. WHAT ACTION IS IMPORTANT WHEN TURNING THE CLIENT TO A
LATERAL POSITION? - ANSObserve the SCDs continue to inflate and deflate when the
client is turned.
While the PN assists a postoperative client with an incentive spirometer, the client
experiences wound evisceration. WHAT ACTION SHOULD THE PN TAKE? - ANSCall for
immediate assistance.
The PN finds a postoperative client lying in bed with a unsecured surgical dressing. After
reinforcing the dressing, WHAT FOLLOW UP ASSESSMENT IS MOST IMPORTANT FOR
THE PN TO IMPLEMENT? - ANSVital signs measurement.
The scope of practice for the PN includes which CLIENT ASSESSMENT? - ANSAn agitated
client with b/l wrist restraints.
Which intervention is within the scope of practice for a PN? - ANSDemonstrating deep
breathing and coughing to a postoperative client.
Which nursing activity is within the scope of practice for a PN? - ANSObserve client rotate
the SQ site for an insulin pump.
The nurse is assessing care for residents on 12-bed unit in an extended care facility. The
staff consists of 1 unlicensed UAP and 1 certified medication aide. WHICH TASK SHOULD
THE NURSE PERFORM? - ANSChange a hydrocolloid dressing for a client with a stage II
pressure ulcer.
A PN who works on a 16-bed of an extended care facility with an additional P and a UAP is
told that the other PN will not be in because of illness. The facility manager agrees to obtain
another UAP for the day. WHICH ACTION SHOULD THE PN TAKE? - ANSPrioritize
assessment of safety issues in addition to administration of daily medication.
In working with UAP to provide care for an immobile client, WHICH TASK SHOULD THE
NURSE PERFORM, RATHER THAN THE UAP? - ANSCover a skin tear with a transparent
dressing.
A nurse sees a college taking drugs from the hospital unit. WHAT ACTION SHOULD THE
NURSE TAKE? - ANSReport the incident to the person in charge of the unit or nursing
supervisor.
The PN finds a client who is assigned to another nurse bleeding from an IV site and the IV
tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding.
,WHAT ACTION SHOULD THE PN TAKE NEXT? - ANSEnter computer documentation of the
findings and the application of a dressing.
During report, the PN is told that a client has 4+ pitting edema of both feet and ankles. The
PN observes the client's lower extremities and finds 2+ pitting edema b/l. WHAT ACTION
SHOULD THE PN TAKE? - ANSEnter computer documentation of the finding.
The UAP working in a small community hospital obtains 0800 V/S measurements of clients
on the unit. In reviewing these vital signs, WHICH MEASUREMENT WARRANTS
IMMEDIATE INTERVENTION BY THE NURSE? - ANSA one-month old infant with a HR of
80 bpm.
The nurse is assigned to care for four children. WHICH CHILD SHOULD BE ASSESSED
FIRST? - ANS18 month old who has cystic fibrosis and is wheezing.
On a short-staffed unit of a long-term are facility, it is most important that the nurse assign
the UAP to complete this morning care for the resident with which problem first? -
ANSFrequent episodes of fecal incontinence.
Which client should the nurse assess first? - ANSA client who is ambulating with partial
weight-bearing after a total hip replacement.
After report, the nurse receives the laboratory values for 4 clients. Which client requires the
nurse's immediate intervention? The client who is: - ANSTrembling and has a glucose level
of a 50 mg/dL.
The PN who is working as the charge nurse at an extended care facility is making
assignments for the UAP working a 12-hour shift. WHICH RESOURCE IS MOST
IMPORTANT IN GUIDING THE PN's assignments of the UAPs? - ANSThe state's Nurse
Practice Act regarding delegation to unlicensed personnel.
In caring for a client following a BKA, WHICH TASK IS BEST FOR THE NURSE TO
DELEGATE TO THE UAP who is assisting with the care of this client? - ANSEmpty and
measure the drainage in the suction drainage device.
Which client should the nurse assign to a UAP? - ANSA client who has a regular HR after a
pacemaker replacement and now needs to ambulate.
Which task could the nurse safely delegate to the UAP? - ANSOral feeding of a two-year-old
child after application of a hip spica cast.
The nurse assigns a UAP to feed a client who is at risk for aspiration. To ensure that the task
is safely delegated, WHAT ACTION SHOULD THE NURSE IMPLEMENT? - ANSObserve
the UAP's ability to implement precautions during feeding.
The nurse is in charge of a nursing unit in a long term care facility. WHICH TASK IS BEST
FOR THE NURSE ASSIGN TO A UAP who is helping with the care of SEVERAL clients? -
ANSCleanse the perineal area of client with urinary incontinence.
, After morning dressing changes are completed, a male client who has paraplegia
contaminates his ischial decubiti dressing with a diarrheal stool. WHAT ACTIVITY IS BEST
FOR THE NURSE TO ASSIGN TO THE UAP? - ANSProvide perianal care and collect clean
linens for the dressing change.
A new protocol for fall prevention is being implemented on the medical unit. During safety
rounds, the nurse identifies that a UAP has omitted a vital component of the protocol.
AFTER IMPLEMENTING THE MISSING COMPONENT, WHAT ACTION SHOULD THE PN
TAKE? - ANSSupervise the UAP after reviewing the protocol.
The nurse asks a UAP for feedback about an assigned client. Instead of responding, the
UAP walks away from the nurse, ignoring the question. WHAT ACTION IS THE BEST FOR
THE NURSE TO TAKE? - ANSApproach the UAP to discuss the behavior and obtain the
information needed about the client.
The principles of client advocacy is best demonstrated when the nurse exhibits which
behaviors on behalf of the client? - ANSA nuriewho translates completes for a
Spanish-speaking client to the HCP during rounds.
A client's daughter phones the charge nurse to report that the night nurse did not provide
good care for her mother. WHAT RESPONSE SHOULD THE NURSE TAKE? - ANSAsk for a
description of what happened during the night.
A female client complains to the nurse about being admitted to a semi-private room and
expresses her displeasure because she requested a private room prior to admission. WHAT
RESPONSE IS BEST FOR THE NURSE TO PROVIDE TO THIS CLIENT? - ANSYour
healthcare provider must provide a written request to get you a private room.
Which nurse's behavior is a breach of client confidentiality according to the Health Insurance
Portable Accountability Act (HIPPA) regulations? - ANSA daily report sheet with the
information of the team's clients is taken home.
The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and
another staff
member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis
of terminal cancer. WHAT IS THE BEST NURSING ACTION? - ANSApproach the individuals
involved and ask them to stop.
A terminally ill client and his family are requesting hospice care after discharge from the
hospital an ask the nurse to explain what kind of care they should expect. The nurse should
indicate that hospice philosophy focuses on what aspect of health care? - ANSEnhance
symptom management to improve end of life quality.
A 54-year-old client was informed two days ago that the dx is terminal cancer. WHICH
INTERVENTION WOULD BE MOST HELPFUL FOR THE SPOUSE AT THIS TIME? -
ANSAsk the spouse to participate in the client's care within his/her capabilities and desires.
A client returns to the postoperative unit following an open reduction and internal fixation of a
hip fx. the PN applies the prescribed sequential compression device (SCD) to both lower
extremities. WHAT ACTION IS IMPORTANT WHEN TURNING THE CLIENT TO A
LATERAL POSITION? - ANSObserve the SCDs continue to inflate and deflate when the
client is turned.
While the PN assists a postoperative client with an incentive spirometer, the client
experiences wound evisceration. WHAT ACTION SHOULD THE PN TAKE? - ANSCall for
immediate assistance.
The PN finds a postoperative client lying in bed with a unsecured surgical dressing. After
reinforcing the dressing, WHAT FOLLOW UP ASSESSMENT IS MOST IMPORTANT FOR
THE PN TO IMPLEMENT? - ANSVital signs measurement.
The scope of practice for the PN includes which CLIENT ASSESSMENT? - ANSAn agitated
client with b/l wrist restraints.
Which intervention is within the scope of practice for a PN? - ANSDemonstrating deep
breathing and coughing to a postoperative client.
Which nursing activity is within the scope of practice for a PN? - ANSObserve client rotate
the SQ site for an insulin pump.
The nurse is assessing care for residents on 12-bed unit in an extended care facility. The
staff consists of 1 unlicensed UAP and 1 certified medication aide. WHICH TASK SHOULD
THE NURSE PERFORM? - ANSChange a hydrocolloid dressing for a client with a stage II
pressure ulcer.
A PN who works on a 16-bed of an extended care facility with an additional P and a UAP is
told that the other PN will not be in because of illness. The facility manager agrees to obtain
another UAP for the day. WHICH ACTION SHOULD THE PN TAKE? - ANSPrioritize
assessment of safety issues in addition to administration of daily medication.
In working with UAP to provide care for an immobile client, WHICH TASK SHOULD THE
NURSE PERFORM, RATHER THAN THE UAP? - ANSCover a skin tear with a transparent
dressing.
A nurse sees a college taking drugs from the hospital unit. WHAT ACTION SHOULD THE
NURSE TAKE? - ANSReport the incident to the person in charge of the unit or nursing
supervisor.
The PN finds a client who is assigned to another nurse bleeding from an IV site and the IV
tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding.
,WHAT ACTION SHOULD THE PN TAKE NEXT? - ANSEnter computer documentation of the
findings and the application of a dressing.
During report, the PN is told that a client has 4+ pitting edema of both feet and ankles. The
PN observes the client's lower extremities and finds 2+ pitting edema b/l. WHAT ACTION
SHOULD THE PN TAKE? - ANSEnter computer documentation of the finding.
The UAP working in a small community hospital obtains 0800 V/S measurements of clients
on the unit. In reviewing these vital signs, WHICH MEASUREMENT WARRANTS
IMMEDIATE INTERVENTION BY THE NURSE? - ANSA one-month old infant with a HR of
80 bpm.
The nurse is assigned to care for four children. WHICH CHILD SHOULD BE ASSESSED
FIRST? - ANS18 month old who has cystic fibrosis and is wheezing.
On a short-staffed unit of a long-term are facility, it is most important that the nurse assign
the UAP to complete this morning care for the resident with which problem first? -
ANSFrequent episodes of fecal incontinence.
Which client should the nurse assess first? - ANSA client who is ambulating with partial
weight-bearing after a total hip replacement.
After report, the nurse receives the laboratory values for 4 clients. Which client requires the
nurse's immediate intervention? The client who is: - ANSTrembling and has a glucose level
of a 50 mg/dL.
The PN who is working as the charge nurse at an extended care facility is making
assignments for the UAP working a 12-hour shift. WHICH RESOURCE IS MOST
IMPORTANT IN GUIDING THE PN's assignments of the UAPs? - ANSThe state's Nurse
Practice Act regarding delegation to unlicensed personnel.
In caring for a client following a BKA, WHICH TASK IS BEST FOR THE NURSE TO
DELEGATE TO THE UAP who is assisting with the care of this client? - ANSEmpty and
measure the drainage in the suction drainage device.
Which client should the nurse assign to a UAP? - ANSA client who has a regular HR after a
pacemaker replacement and now needs to ambulate.
Which task could the nurse safely delegate to the UAP? - ANSOral feeding of a two-year-old
child after application of a hip spica cast.
The nurse assigns a UAP to feed a client who is at risk for aspiration. To ensure that the task
is safely delegated, WHAT ACTION SHOULD THE NURSE IMPLEMENT? - ANSObserve
the UAP's ability to implement precautions during feeding.
The nurse is in charge of a nursing unit in a long term care facility. WHICH TASK IS BEST
FOR THE NURSE ASSIGN TO A UAP who is helping with the care of SEVERAL clients? -
ANSCleanse the perineal area of client with urinary incontinence.
, After morning dressing changes are completed, a male client who has paraplegia
contaminates his ischial decubiti dressing with a diarrheal stool. WHAT ACTIVITY IS BEST
FOR THE NURSE TO ASSIGN TO THE UAP? - ANSProvide perianal care and collect clean
linens for the dressing change.
A new protocol for fall prevention is being implemented on the medical unit. During safety
rounds, the nurse identifies that a UAP has omitted a vital component of the protocol.
AFTER IMPLEMENTING THE MISSING COMPONENT, WHAT ACTION SHOULD THE PN
TAKE? - ANSSupervise the UAP after reviewing the protocol.
The nurse asks a UAP for feedback about an assigned client. Instead of responding, the
UAP walks away from the nurse, ignoring the question. WHAT ACTION IS THE BEST FOR
THE NURSE TO TAKE? - ANSApproach the UAP to discuss the behavior and obtain the
information needed about the client.
The principles of client advocacy is best demonstrated when the nurse exhibits which
behaviors on behalf of the client? - ANSA nuriewho translates completes for a
Spanish-speaking client to the HCP during rounds.
A client's daughter phones the charge nurse to report that the night nurse did not provide
good care for her mother. WHAT RESPONSE SHOULD THE NURSE TAKE? - ANSAsk for a
description of what happened during the night.
A female client complains to the nurse about being admitted to a semi-private room and
expresses her displeasure because she requested a private room prior to admission. WHAT
RESPONSE IS BEST FOR THE NURSE TO PROVIDE TO THIS CLIENT? - ANSYour
healthcare provider must provide a written request to get you a private room.
Which nurse's behavior is a breach of client confidentiality according to the Health Insurance
Portable Accountability Act (HIPPA) regulations? - ANSA daily report sheet with the
information of the team's clients is taken home.
The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and
another staff
member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis
of terminal cancer. WHAT IS THE BEST NURSING ACTION? - ANSApproach the individuals
involved and ask them to stop.
A terminally ill client and his family are requesting hospice care after discharge from the
hospital an ask the nurse to explain what kind of care they should expect. The nurse should
indicate that hospice philosophy focuses on what aspect of health care? - ANSEnhance
symptom management to improve end of life quality.
A 54-year-old client was informed two days ago that the dx is terminal cancer. WHICH
INTERVENTION WOULD BE MOST HELPFUL FOR THE SPOUSE AT THIS TIME? -
ANSAsk the spouse to participate in the client's care within his/her capabilities and desires.
