Hesi Practice Test Flashcards 2025

Terms in this set (100) Which information should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP) who is newly assigned to the unit? Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. Determine if pain subsides 20 minutes after a client receives an injection. Report signs of infection in urine that collects in a bedside drainage unit. Observe how clients are using an incentive spirometer after surgery. Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. Rationale Information about the basic care of clients, such as positioning (A), should be specific to a common intervention or treatment and should focus on tasks within the scope of the UAP's assignment. (B, C, and D) are elements of assessment or evaluation, which is the responsibility of a licensed nurse. A client with chronic kidney disease (CKD) begins to manifest Kussmaul respirations. What action should the practical nurse implement? Administer prescribed sodium bicarbonate. Restrict sodium and fluid intake. Provide additional potassium rich foods. Give prescribed sevelamer (Renagel). Administer prescribed sodium bicarbonate. Rationale Kussmaul breathing occurs in an effort to compensate for metabolic acidosis, which results from kidney’s inability to excrete acid products such as ammonia, which is normally buffered by bicarbonate. To help correct this imbalance, supplements such as sodium bicarbonate (A) are prescribed and should be administered promptly. Although (B) is indicated in CKD, this does not address the client's onset of signs of metabolic acidosis. (C) is not recommended due to the kidneys inability to excrete potassium. Renagel (D) is a phosphate binder that reduces phosphate absorption and elevated serum levels that occur with kidney failure. lOMoAR cPSD| The practical nurse (PN) is assisting the nurse with the care of a newborn immediately after delivery. Which action should the PN perform first? Dry the infant and wrap in a warming blanket. Stimulate respirations by rubbing the newborn's back. Evaluate skin color, heart rate, and muscle tone. Give supplemental oxygen using blow- by technique. Dry the infant and wrap in a warming blanket. Rationale After delivery, the newborn's mouth and nose should be suctioned with a bulb syringe to clear the airway and prevent aspiration. To prevent cold stress, the newborn should be dried and and wrapped in warm blanket (A). After evaluation (C), (B and D) should be provided if indicated. A male client with recurrent angina is receiving oxygen at 2 liters/minute and begins to complain that he feels "funny" in his chest. The telemetry monitor reveals a rapid narrow QRS complex at 170 beats/minute. Which action is most important for the practical nurse to implement? Report the findings to the charge nurse. Tell the client to remain on bedrest. Obtain the client's pulse oximetry reading. Call the rapid response team. Report the findings to the charge nurse. Rationale The client is likely experiencing supraventricular tachycardia (SVT), which should be reported to the charge nurse (A) and healthcare provider for immediate treatment. Bedrest (B) minimizes myocardial demand for oxygen, but rest does not change the rate of SVT. (C) may be indicated, but the first action is to report the findings. (D) is indicated if the client's rhythm progresses to ventricular tachycardia (VT) or ventricular fibrillation. lOMoAR cPSD| Depth of respirations. A client who sustained a C4 injury in a head-on automobile collision is Rationale admitted to the neurological unit. The cervical plexus (first 4 cervical nerves) includes the phrenic Which priority assessment should the nerve, which innervates the diaphragm; therefore a C-4 cord practical nurse (PN) monitor? injury can cause respiratory distress, which requires close monitoring of respiratory depth (A) to monitor the adequacy of Depth of respirations. oxygenation, which is the priority. Breathing is the priority over Neuro focused checks. neurological checks (B), pedal pulses (C), and blood pressure Pedal pulses. (D). Blood pressure. The practical nurse (PN) administer Take client's blood pressure in an hour. furosemide (Lasix) 60 mg PO instead the client's prescribed dose of 20 mg. Rationale What action is most important for the The onset of oral dosing of Lasix is 30-60 minutes, peaking 60- PN to implement? 70 minutes after administration. Blood pressures should be monitored in an hour (D) to identify signs of hypovolemia during Complete an adverse occurrence periods of diuresis. (A) is not indicated unless the client report. experiences a severe adverse response. Documentation (B) is implemented after drug administration. Although the client Record dose on the medication should be aware of side effects (C), the priority is assessment administration record. for adverse effects during the peak action of oral Lasix. Reinforce with the client about the side effects of Lasix. Take client's blood pressure in an hour. lOMoAR cPSD| A client comes to the clinic and Radial pulse 130 receives a prescription for a urinary tract infection (UTI). Which finding is Rationale important for the practical nurse (PN) Tachycardia (C) may indicate urosepsis and should be reported to report to the healthcare provider to the healthcare provider before the client is allowed to go before allowing the client to go home? home after the clinic visit. Dysuria (A), mild temperature (B), and bacteria in the urine (D) are expected findings with a UTI. Complains of dysuria. Temperature 100.4 F (38 C). Radial pulse 130. Urinalysis with 3+ bacteria. An older client who takes digoxin Vomiting. (Lanoxin) daily calls the clinic about not feeling well. The new onset of which Rationale finding should the practical nurse In older clients, nausea and vomiting (A) are early signs of advise the client to come for a visit with digoxin toxicity, which can occur due to cumulative effects, even the healthcare provider? with subtoxic digoxin levels. Bradycardia, not tachycardia (B) is a sign of digoxin toxicity. Constipation (C) is not related to Vomiting. digoxin toxicity. Tinnitus (D) is a symptom of aspirin toxicity. Tachycardia. Constipation. Tinnitus. lOMoAR cPSD| At the beginning of the shift, the practical nurse (PN) is reconciling a client's medication administration record, the prescriptions, and the dispensed drugs. Which available medication should the PN give? Prescribed digoxin (Lanoxin); dispensed digoxin immune FAB (DigiFab). Prescribed nitroglycerin (Nitrogard, transmucosal); dispensed nitroglycerin (Nitrostat SL). Prescribed albuterol (Proventil); dispensed albuterol (Ventolin). Prescribed verapamil (Isoptin); dispensed verapamil SR (Calan SR). Prescribed albuterol (Proventil); dispensed albuterol (Ventolin). Rationale Albuterol (Ventolin and Proventil) are the same drug, and should be administered as prescribed. (A, B, and C) are the not the same drug and should not be administered as trade or generic equivalents. A client is transferred to the rehabilitation unit after a total knee replacement. The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to move the client from the bed into the chair by pivoting and without weight-bearing on the operative leg. What is the best way for the PN to ensure the UAP safely transfers the client? Ask about prior care experiences. Describe the safe transfer method. Review the UAP's skill checkoff list. Assist the UAP with the first transfer. Assist the UAP with the first transfer. Rationale Assisting the UAP during the first client transfer is the best way to observe and evaluate if the UAP is safely mobilizing the client (D). (A, B, and C) are less effective in evaluating the UAP's skill performance. lOMoAR cPSD| Which measure should the practical nurse implement as the most effective measure to help decrease client care cost? Wait to dispose of sharp containers when they are completely full. Store open irrigation bottles of normal saline in refrigerator for up to 48 hours. Return unused dressing supplies from bedside to supply cart. Use filtered tap water instead of sterile water for jejunostomy tube feeding. Use filtered tap water instead of sterile water for jejunostomy tube feeding. Rationale The gastrointestinal system is not a sterile system, so filtered, tap water (D) can be used instead of sterile water for use via a jejunostomy tube. Sharp containers should be emptied when approximately one-half to two-thirds full, not (A), to prevent uncapped needles from sticking up and causing injury. Open bottles of normal saline for irrigation do not contain a preservative, so opened bottles of irrigation fluids should be discarded after 24 hours, not (B). Returning supplies that originated from a client's bedside unit to a unit's general supply storage area is a source of nosocomial transmission (C). An older male client who drove himself Apply telemetry electrodes to the client's chest. to the emergent care clinic with chest pain is placed on a cardiac monitor with Rationale oxygen per nasal cannula at 2 Since the client is presenting with chest pain, the risk of liters/minute as an IV access is becoming unstable at any time due to possible acute coronary obtained. Which intervention should syndrome (ACS) requires that differential assessments are the practical nurse implement first? implemented immediately. First telemetry electrodes (C) should be applied for early recognition of ST segment changes and life Review history for cardiac disease. threatening arrhythmias. Although (A) provides information about the client's risk for ACS, the immediate need is analysis of Collect blood specimens for laboratory cardiac rhythm. Specimens for diagnostic analysis (B) should be studies. obtained after cardiac rhythm assessment, so treatment, such as the need for nitroglycerin (D) can be prescribed and Apply telemetry electrodes to the implemented. client's chest. Administer sublingual nitroglycerin. lOMoAR cPSD| When reviewing the need to take warfarin sodium (Coumadin) with a male client who is recently diagnosed with chronic atrial fibrillation, what explanation should the practical nurse reinforce with the client? Prevent emboli. Stop plaque buildup. Dissolve blood clots. Control heart rhythm. Prevent emboli. Rationale Atrial fibrillation is a condition in which the upper two chambers of the heart beat irregularly with the lower two chambers, which is a chaotic rhythm that causes the blood to pool and clot, which leads to stroke. Coumadin helps to prevent the formation of emboli (A) by blocking the action of vitamin K in the liver and reducing the amount of clotting factors in the blood. Coumadin does not stop the buildup of plaque (B), dissolve existing blood clots (C), or control the rhythm of the heart (D). When monitoring a newborn, which observation should the practical nurse report to the healthcare provider? Rectal temperature of 37.6 C. Axillary temperature of 37.1 C. Heart rate of 110 beats per minute. Respiration rate of 40 breaths per minute Heart reate of 110 beats per minute. Rationale The normal range for the heart rate in a newborn is 120 to 160 beats/minute, so a heart rate of 110 beats/minute should be reported to the healthcare provider (C). (A, B, and D) are within normal limits. Newborn temperature ranges from 97.7 F to 99.4 F, 36.5 C to 37.5 C, and the normal respiratory rate in a newborn (D) is 30 to 60 breaths/minute. The practical nurse (PN) is monitoring a client who is 3 hours post-cardiac catheterization of the right femoral artery. Which client finding requires further action by the PN? Right leg with 1+ to 2+ edema. Ecchymosis at femoral puncture site. Loss of right pedal pulse. Blood pressure of 154/88. Loss of right pedal pulse. Rationale Loss of a pedal pulse (C) is indicative of thrombus or embolism in the right femoral artery and requires immediate follow-up to prevent distal tissue damage. (A) is not a critical finding that requires action at this time. (B) is an expected finding due to arterial puncture. Although stress or pain can cause an elevation of blood pressure (D), the priority finding is obstructed perfusion that obliterates the pulse. lOMoAR cPSD| A child is admitted for severe abdominal pain and possible appendicitis. Laboratory and xray studies are prescribed. During the diagnostic period, the practical nurse should implement which nursing actions? (Check all that apply.) Select all that apply A. Maintain child's comfort. B. Relieve parents' and child's anxiety . C. Prepare for surgery. D. Give oral home medications. E. Encourage ambulation. A. Maintain child's comfort. B. Relieve parents' and child's anxiety. C. Prepare for surgery. Rationale (A, B, and C) are correct. During the diagnostic period, the PN should focus on maintaining the child's comfort (A), relieving anxiety (B), and preparing the child for possible surgery (C). The child should be maintained NPO for possible surgery, and routine oral medications should be withheld (D). (E) should be minimized to bathroom privileges to maintain the child's comfort preoperatively. Which directions should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP)? Report the total urine output for the client on intake and output. Offer the client 6 grams of carbohydrates during each meal. Obtain the vital signs for the client who is returning from surgery. Observe and report any signs of infection in the client's urine. Report the total urine output for the client on intake and output. Rationale Directions should be given to the UAP that are clear and precise about basic client care, such as the collection of data related to intake and output (A). (B) requires nursing judgment of the licensed nurse. (C and D) are client assessment, which is a component of the nursing process and the responsibility of the licensed nurse. lOMoAR cPSD| A female client reports to the practical nurse (PN) that she has had 10 watery diarrhea stools in the last 24 hours and is feeling dizzy. Which intervention should the PN implement first? Review the client's white blood cell count. Ask if she has recently traveled to foreign country. Obtain her vital signs lying and standing. Rationale The client is experiencing fluid volume deficit related to diarrhea and dehydration evidenced by feeling dizzy, so the client's lying and standing vital signs (D) should be taken first to identify orthostatic changes that require additional intervention. Although (A, B, and C) should be implemented, assessment of the client's status should be performed first to provide safe care. Collect a stool sample for culture for C. difficile. Obtain her vital signs lying and standing. Which action should the practical nurse perform first for a child who is injured on the school grounds and has an obvious mis-alignment of the lower forearm? Remove the child's finger rings. Assess and document the child's level of pain. Evaluate the child's range of motion. Place arm in a sling at level of the child's heart. Remove the child's finger rings. Rationale The child is at risk for swelling in the distal areas of the affected arm and hand. Removal of finger rings (A) should be implemented first to remove any potential constriction that may occur after tissue injury or fracture of the lower arm. Pain assessment (B), neuromuscular assessment (C), and elevation with immobilization (D) should be implemented after removing any rings which are a source of potential complication after injuries to a traumatized extremity. lOMoAR cPSD| A client arrives in the clinic complaining of radiating back pain. Which finding related to a possible dissecting aneurysm should the practical nurse (PN) report to the healthcare provider? Ripping chest pain and blood pressures of 150/90 in right arm and 120/70 in left arm. Sudden right flank pain with gross hematuria. Ripping chest pain and blood pressures of 150/90 in right arm and 120/70 in left arm. Rationale A dissecting aneurysm is a tearing of the intima of a major artery, such as the ascending aorta, and classically presents with the onset of sudden, severe, ripping pain that moves. Depending on the location, as the intima of the artery tears, a difference in the extremity perfusion (A), deceased urine output, or petechiae on the feet occur. (B) is characteristic of a kidney stone (renal lithiasis). (C) occurs with acute biliary colic and cholelithiasis. (D) describes pain associated with an intervertebral disc herniation. Sharp epigastric pain that radiates to the scapula. Lower back pain that radiates down back of the leg and is more intense with coughing. A client in a nursing home becomes violent and verbally threatens an unlicensed assistive personnel (UAP). Which is the best way for the practical nurse (PN) in charge during the shift to handle the staff's reaction to the incident? Encourage UAP to deal with it privately to prevent compromising client confidentiality. Offer a group discussion session so staff can share their thoughts and feelings. Invite staff out after hours to help distract them from the disturbing client event. Refer the UAP to human resources department for a counseling session with a therapist. Offer a group discussion session so staff can share their thoughts and feelings. Rationale A Critical Incident Stress Debriefing (CISD) involves expression of personal feelings, discussion, and working on unresolved emotional issues to minimize post traumatic stress for the staff member. A CISD is the best action for the PN in charge to take (B) in conjunction with the guidance and assistance of the nursing supervisor in the facility. Professional, private discussions among the caregivers do not breach client confidentiality (A). (C) is unprofessional and denies and blunts emotions through avoidance. Counseling is an option but it delays (D) processing the event in an expedient manner. lOMoAR cPSD| Which finding in a 4-month-old infant warrants further investigation by the practical nurse? Wets 8 diapers a day. Grunts with expiration. Protruding abdomen. Inability to sit up without support. Grunts with expiration. Rationale Grunting on expiration (B) is a sign of respiratory distress and requires immediate attention. (A, C, and D) are normal findings for a 4-month-old. The practical nurse (PN) assigns the Take vital signs for any client with abnormal findings. task of obtaining vital signs for all the clients on a 24-bed unit to an Rationale experienced unlicensed assistive To ensure safe care, the PN should take the vital signs for any personnel (UAP). What action should client with abnormal results to evaluate the client's condition (B). the PN take to ensure the clients are Trends should be evaluated on an ongoing basis, not just at the receiving safe care? end of the shift (A). Although (C) should be implement, specific information and parameters for abnormal findings should be Review vital signs trends of each client at included in the assignment to the UAP. Obtaining vital signs is end of shift. within the scope of the UAPs assignment, so (D) is not necessary. Take vital signs for any client with abnormal findings. Tell the UAP to report any abnormal vital signs. Accompany the UAP while obtaining vital signs. lOMoAR cPSD| The practical nurse (PN) is caring for a Determine client's priority needs for supportive care. male client who is dying and assigns components of the client's care to the Rationale UAP. Which intervention should the PN The PN should determine the priority supportive needs (C) to implement? provide based on the client's plan of care. (A, B, and D) are examples of assistive, supportive measures that a UAP can Sit with the client who is withdrawn, provide to a dying client and his family. crying, or upset. Obtain client vital signs and complaints of discomfort. Determine client's priority needs for supportive care. Listen to family's feeling about the client's life choices. Which action is most important for the Monitor client's serum pre-albumin leveles. practical nurse (PN) to implement for a client who has a Stage I pressure ulcer? Rationale Wound healing requires good nutritional status that is best Debride ulcer using a wet to dry evidenced with serum pre-albumin levels (D), which provide the dressing. most useful marker of what the client has eaten and what nutrients the client has absorbed, digested, and metabolized. A Apply an antibiotic ointment to the stage I ulcer does not require debridement (A) or an ointment wound. (B). An adequate intake of vitamin C is important for wound healing but serum pre-albumin gives a better overall picture of Encourage intake of additional vitamin C. the client's nutritional status (C). Monitor client's serum pre-albumin levels. lOMoAR cPSD| The practical nurse (PN) is changing the ileostomy collection bag on a client who is 6-days postoperative for a total colectomy. Which finding requires additional action by the PN? The drainage is brown liquid. Skin maceration around stoma. The stoma bleeds when touched. Foul odor noted when bag removed. Skin maceration around stoma. Rationale Maceration around the stoma (B) may indicate that the ileostomy bag is leaking and the peristomal skin is irritated by liquid stool from the ileum. (A and D) are expected findings. (C) should be monitored, but peristomal skin destruction is painful and affects the client's recovery. After reviewing discharge instructions with a male client who has hepatitis C, what statement by the client indicates to the practical nurse that the client understands his disease? "I will avoid taking any products with acetaminophen, such as Tylenol." "I will eliminate alcohol consumption until my infection subsides." "I should eat a diet rich in dark green leafy vegetables." "I understand that my other medications doses need to be increased." "I will avoid taking any products with acetaminophen, such as Tylenol." Rationale Tylenol is metabolized in the liver and should be avoided in clients with liver disease (A). Alcohol should also be avoided for a life-time because Hepatitis C is a chronic disease (B). Although the client with liver disease should eat a healthy diet, dark green leafy vegetables are not a specific recommendation (C). Due to the liver's decreased function, dosages are usually reduced, not increased (D). lOMoAR cPSD| Which technique should the practical nurse implement when providing care to a pediatric client? Weigh the mother and infant together then subtract the mother's weight. Tell a 5-year-old child to blow bubbles during an invasive painful procedure. Pinch the child's nose shut to encourage child to swallow oral medications. Administer intramuscular injections in the vastus lateralis for a 9-month-old. Administer intramuscular injections in the vastus lateralis for a 9- month-old. Rationale The vastus lateralis site should be used for an infant (D) until other intramuscular sites develop, which occurs as the child learns to walk. (A) does not provide the most accurate data. (B) is a distraction technique, which may not be effective during invasive painful procedures. (C) places the child at risk for aspiration and is not an acceptable approach. The practical nurse (PN) is checking the charge slips for a client who receives supplies from the unit's central supply areas. Which charge should the PN validate on a daily basis? Daily use of an indwelling urinary catheter bedside drainage system. PRN medications from the automated medication dispensing system. Ongoing use of an IV infusion pump. Dressing supplies at the bedside. Ongoing use of an IV infusion pump. Rationale Documentation of usage of medical equipment on a daily basis may change based on the client's prescriptions. The current use and implementation of prescriptions for daily or continuous use of an infusion pump (C) should be validated daily. Disposable supplies, such as (A and D), are a one-time charge that is made when the supplies are taken from the supply area and are not charged to the client on a daily basis. PRN medications are charged when the medication is retrieved from an automated medication dispensing system (B). lOMoAR cPSD| A group of practical nurses (PNs) who Client acuity and census. work on a medical-surgical unit believe they are understaffed. Which data Rationale should the PNs consider when When presenting the need for increased staff, the PNs should preparing the justification for present the request using staffing guidelines that consider client additional staff? acuity, number of clients, and length of stay (B). Client characteristics and staffing ratios differ across states (A) and are Staffing ratios in other states. not applicable in a particular healthcare delivery facility. (C and Client acuity and census. D) are influenced by inexperienced staff, a shortage of nurses in Overtime payment and unfilled the area, or client opinion polls about client care, staff positions. behaviors, and hospital services. Number and frequency of client complaints. A client is being discharged after repair Take a PRN antiemetic with early signs of nausea. of a retinal detachment. The practical nurse (PN) reviews the written Rationale discharge information with the client To minimize increased intraocular pressure, it is most important and family. Which instruction should that the client take an antiemetic as soon as nausea is the PN emphasize to the client when experienced (B) to prevent vomiting that can cause arriving at home? displacement of the retinal repair. Although (A and C) should be implemented depending on the procedure and location of the Limit reading or writing for 3 weeks. retinal tear, prevention of postoperative vomiting is most essential. The PN should determine if the client is able to Take a PRN antiemetic with early signs of correctly self administer eye drops (D). nausea. Keep the head flat and centered when lying down. Self administer eye medications. lOMoAR cPSD| The practical nurse (PN) is reviewing the medical record for a male client scheduled for an electroconvulsive therapy (ECT) and determines there is no signed consent form. What action should the PN take? Ask the client if his verbal consent can be relayed to the healthcare provider. Witness the client's signature on the consent form with another nurse. Notify the healthcare provider that the client's consent has not been signed. Verify the consent form for hospitalized care and treatment on admission is signed. Notify the healthcare provider that the client's consent has not been signed. Rationale The healthcare provider is responsible for explaining and obtaining consent for invasive treatments, such as ECT, which is implemented under specific state guidelines. The healthcare provider should be notified to obtain the client's signed consent for ECT. (A and C) do not comply with legal guidelines. (D) does not include specific treatments, such as ECT. Which action should the practical nurse implement when administering an 8 ounce can of a concentrated nutritional formula via a client's gastrostomy tube (GT)? Determine the gastric residual's pH before starting the feeding at prescribed rate. Obtain stool specimen for culture of diarrhea stool that occurred after first feeding. Discards 60 ml of gastric residual before giving formula. Give 30 ml of tap water after administration of formula. Give 30 ml of tap water after administration of formula. Rationale After administering formula, additional water should be given (D) to prevent obstruction of the GT and to provide the client with additional hydration. Although (A) provides evidence of aspirated gastric secretions, checking the pH with each feeding is not indicated. (B) is not indicated for administration of a concentrated formula. Residual should be returned to the client's stomach to prevent electrolyte imbalance (C). lOMoAR cPSD| Which task could the practical nurse assign to an unlicensed assistive personnel (UAP)? Reinforce teaching a mom how to position infant for sleep. Observe and record the presence of an infant's Moro reflex. Verify identification arm bands when infant is left in mom's room. Determine adequacy of mother's first void after catheter removal. Verify identification arm bands when infant is left in mom's room. Rationale Delivering an infant from the nursery to the mother's room and verifying the identification on both arm bands is a task that could be assigned to a UAP (C). The task is a predictable, routine task on a unit. Reinforcing teaching about infant sleeping positions (A), assessing for normal infant reflexes (B), and determining adequacy of the quantity of urine output after a catheter (D) require nursing judgment and should not be assigned. A ssigned tasks are tasks that nursing assistants are trained, hired, and paid to perform. A number of clients have arrived for care in a crowded emergent care center. Which assignment should the practical nurse (PN) accept? Flush a cllient's eyes who was exposed to a facial chemical splash. Obtain the history of an adult who attempted suicide. Accept an incoming trauma victim of a vehicle collision. Insert nasogastric tube for an older adult with abdominal distention. Insert nasogastric tube for an older adult with abdominal distention. Rationale Insertion of a nasogastric tube (D) is within the scope of the PN. Clients who have experienced caustic eye trauma (A), a suicide attempt (B), and admission of a trauma victim (C) require the knowledge and skill of an experienced nurse. lOMoAR cPSD| The practical nurse (PN) is reviewing the morning laboratory results for a group of assigned clients. Which finding should the PN report to the healthcare provider first? A female client with dysuria and urinalysis reveals presence of 3 to 5 white blood cells. Male client with Hepatitis B exposure has positive serum results for Hepatitis B core antibody. An older client who has received heparin for two weeks with a platelet count of 15,500/mm3. A young adult with rhinorrhea and common cold with an eosinophils count of 20%. An older client who has received heparin for two weeks with a platelet count of 15,500/mm3. Rationale The client in with thrombocytopenia (normal platelets 150,000 to 400,000/mm3) (C) is likely experiencing a complication due to heparin therapy, and requires timely intervention to prevent bleeding. (A) is not significantly abnormal. (B) is an expected finding. (D) is a typical elevation with allergies. The practical nurse (PN) is assisting the nurse with the care of a client with end- stage emphysema who is on a mechanical ventilator. The PN auscultates decreased breath sounds in the right lung fields and notices that the client's neck veins are distended. Which additional assessment should the PN implement to report a tension pnuemothorax to the nurse? Evaluate the client's ventilatory effort against the ventilator. Check the ventilator pressure settings. Inspect the trachea to see if it is midline. Determine if an emergency thoracotomy tray is available. Inspect the trachea to see if it is midline. Rationale Tension pnuemothorax can occur when an emphysematic bullae or blebs ruptures, causing air to accumulate in the pleural space and collapsing the lung. Additional findings are needed to differentiate the onset of right-sided heart failure versus tension pneumothorax, which is manifested by worsening respiratory status, decreased breath sounds on the affected side, distended neck veins, and tracheal deviation from midline (C). The client's findings are due to a pneumothorax, not resisting the ventilator (A). Although (B) should be implemented, pressure changes do not resolve air accumulation with each inspiration. Although emergency insertion of a chest tube is indicated, the thoracotomy tray (D) can be obtained after additional data is reported to the nurse and healthcare provider. lOMoAR cPSD| What client behavior illustrates to the practical nurse that a male client is adapting to the effects of his recent surgery for laryngeal cancer? Has a lack of facial tension. Selects appropriate foods to eat. Looks at surgical site during care. Welcomes visitors with a smile. Looks at surgical site during care. Rationale Surgical intervention for cancer of the larynx includes laryngectomy and radial neck dissection. The willingness to touch or look at the affected area (C) is the best indication that the client acknowledges and accepts the change in appearance. Lack of facial tension (A) or a pleasant social demeanor (D) may be an indication of denial. Although selecting the appropriate foods (B) is important, it does not necessarily reflect the client's adaptation to the change in his body image. The practical nurse (PN) is using bag- mask device to administer artificial ventilation for a three-year-old child. Which method is best to use to create a seal while holding the mask in place? Perform a head-tilt, chin-lift maneuver when spinal trauma is suspected. Place the mask over nose and mouth using a "c-e" one-hand technique. Measure the mask size from the supraorbital rim to the mandible tip. Position a rolled-up towel under the head to aid positioning of the airway. Place the mask over nose and mouth using a "c-e" one-hand technique. Rationale When using one hand to secure the mask snugly against the skin, the rescuer should place the thumb and first finger on top of the mask to create a "c" and place the 3 other fingers (the "e") underneath the chin (B). The jaw thrust maneuver, not (A), should be used when spinal trauma is suspected. The mask should be measured from the bridge of the nose to the chin, not (C) which applies pressure on the eyeballs. (D) causes hyperflexion of the neck, which closes the airway. lOMoAR cPSD| Which individual should the practical nurse (PN) respond to first? A visitor is lying still on the floor in the middle of the unit hallway. The nursing supervisor is waiting to talk with the PN on the phone. An unlicensed assistive personnel who reports a sink is leaking water on the floor. A postoperative client who is requesting medication for pain that is "10" (0-10 scale). A visitor is lying still on the floor in the middle of the unit hallway. Rationale The visitor who is unresponsive on the floor (A) requires immediate attention to determine if resuscitation is indicated. (B) can be contacted after the emergency situation is addressed. (C) can be delegated to the UAP to clean up the water spill and notify maintenance and housekeeping personnel. (D) can be addressed after the emergency or by another nursing team member. A male client with diabetes mellitus (DM) and renal failure decides to refuse hemodialysis. Which action by the practical nurse (PN) supports the client's right for self-determination? Reaffirm that the decision was a good option. Provide additional information for future options. Rationale The client should be given information regarding lifestyle and end-of-life choices (C), such as hospice or the right to change his mind. An opinion or value judgment (A and B) about the client's choice should be avoided. The family's opinion is not necessary (D), and the client's decision should be supported.