Comprehensive Predictor HESI PN Test
Bank
Comprehensive Predictor HESI PN Test
Bank 300+ verified questions and
answers with detailed Rationales
Graded A+ - Brand New Q&As Latest
Which professionally appropriate response should the nurse make when a more stringent
policy for the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers - ANS :C. Ask for
the rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse analyze the
proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional
behavior. Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed assistive
person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse
must do which of the following?
A. Assess the client to be sure ambulation with assistance is an appropriate care measure
B. Ask the client if he or she is ready to ambulate
C. Ask whether the UAP has time to assist the client
D. Ask the charge nurse whether UAPs have ambulated the client during this shift - ANS :A.
Assess the client to be sure ambulation with assistance is an appropriate care measure
Rationale: Prior to delegating any client care responsibilities, the nurse must assess the
client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4
would not constitute an assessment of the client's current status.
HALINTONE 1
, Comprehensive Predictor HESI PN Test
Bank
The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses
to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the
following actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Reexamine the nursing orders
D. Write a new nursing diagnosis - ANS :B. Reexamine the nursing orders
Rationale: The plan needs to be reassessed whenever goals are not met. Nursing
interventions should be examined to ensure the best interventions were selected to assist
the client achieve the goal. The goal may be appropriate, but the client may need more
time to achieve the desired outcome. The manner in which the nursing interventions were
implemented may have interfered with achieving the outcome.
In developing a plan of care for a client with chronic hypertension, which nursing activity
would be most important?
A. Set incremental goals for blood pressure reduction
B. Instruct the client to make dietary changes by reducing sodium intake
C. Include the client and family when setting goals and formulating the plan of care
D. Assess past compliance to medication regimens - ANS :C. Include the client and family
when setting goals and formulating the plan of care
Rationale: In developing a plan of care, nurses engage in a partnership with the client and
family. Nurses do not plan care for clients; instead they plan care with clients and families.
Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most
accurate and effective when carried out in partnership with the client and family. The
other options represent other actions to take, but they will have less overall effectiveness if
the client and family are not part of the plan.
Which nurse is demonstrating the assessment phase of the nursing process?
A.The nurse who observes that the client's pain was relieved with pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals - ANS :C. The nurse
who ask the client how much lunch he or she ate
Rationale: Assessment involves collecting, organizing, validating, and documenting data
about a client. Option 1 represents the evaluation phase. Option 2 represents the
implemention phase. Option 4 represents the planning phase.
HALINTONE 2
, Comprehensive Predictor HESI PN Test
Bank
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that
this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANS :A. Subjective data from a primary source
Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse
interprets that this data is of which type and source?
The nurse feels a client is at risk for skin breakdown because he has only had clear liquids
for the last 10 days (and essentially no protein intake). The nurse would formulate which
diagnostic statement that would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANS :C. Risk for impaired skin integrity
related to malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human
response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2
do not have related factors that are under the control of the nurse (i.e., type of diet
ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or
less than body requirements) and is therefore incomplete. It also does not provide direction
for development of goals and interventions.
The nurse would place which correctly written nursing diagnostic statement into the client's
care plan?
A. Cancer relater to cigarette smoking
B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen
saturation of 91%
C. Imbalance nutrition: more than body requirement related to overweight status
D. Impaired physical mobility related to generalized weakness and pain - ANS :B. Impaired
gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of
91%
Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the
human response) names/labels the problem. The second part (related factors) includes the
HALINTONE 3
, Comprehensive Predictor HESI PN Test
Bank
factors that either contribute to or are probable etiologies of the human response. Some
formats include a third part to the statement for actual (not risk) diagnoses; this third part
consists of the client's signs or symptoms and is joined to the statement with the label as
evidenced by. This type of statement is the most complete. Option 1 is not a nursing
diagnosis but is a medical diagnosis. Options 3 and 4 are vague.
Which of the following outcome goals has the nurse designed correctly for the postoperative
client's plan of care? Select all that apply.
A. Client will state pain is less than or equal to 3 on zero to ten pain scale
B. Client will have no pain
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of
discharge
E. Client will be medicated every 4 hours by the nurse - ANS :C. Client will state pain is less
than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of
discharge
Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic,
and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve
the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect
a postoperative client to be pain free. Option 5 is not a client goal.
The nurse questions if the dosage of a medication is unsafe for the client because of the
client's weight and age. The nurse should take which of the following actions?
A. Administer the medication as ordered by the prescriber
B. Call the prescriber to discuss the order and the nurse's concern
C. Administer the medication, but chart the nurse's concern about the dosage
D. Give the client half the dosage and document accordingly - ANS :B. Call the prescriber to
discuss the order and the nurse's concern
Rationale: Client safety is of the utmost importance when implementing any nursing
intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the
nurse must act as a client advocate and collaborate with the appropriate healthcare team
member to determine the rationale for the order and/or modify the order as necessary. A
nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate
and unsafe.
Which activity would be appropriate for the nurse to delegate to an unlicensed assistive
person (UAP)?
HALINTONE 4
Bank
Comprehensive Predictor HESI PN Test
Bank 300+ verified questions and
answers with detailed Rationales
Graded A+ - Brand New Q&As Latest
Which professionally appropriate response should the nurse make when a more stringent
policy for the use of restraints is introduced on a surgical unit?
A. Use the previous, less restrictive policy conscientiously
B. Express immediate disagreement with the new policy
C. Ask for the rationale behind the new policy
D. Obey the policy but continue to voice disapproval of it to co-workers - ANS :C. Ask for
the rationale behind the new policy
Rationale: Understanding the rationale behind a decision helps the nurse analyze the
proposed change and understand its purpose. Options 1, 2, and 4 represent unprofessional
behavior. Option 1 also places a client's safety at risk.
The nurse assigned to care for a postoperative client has asked an unlicensed assistive
person (UAP) to help the client ambulate in the hall. Before delegating this task, the nurse
must do which of the following?
A. Assess the client to be sure ambulation with assistance is an appropriate care measure
B. Ask the client if he or she is ready to ambulate
C. Ask whether the UAP has time to assist the client
D. Ask the charge nurse whether UAPs have ambulated the client during this shift - ANS :A.
Assess the client to be sure ambulation with assistance is an appropriate care measure
Rationale: Prior to delegating any client care responsibilities, the nurse must assess the
client to assure that the delegation is appropriate to his or her care. Options 2, 3, and 4
would not constitute an assessment of the client's current status.
HALINTONE 1
, Comprehensive Predictor HESI PN Test
Bank
The nurse makes the following entry on the client's care plan: "Goal not met. Client refuses
to ambulate, stating, 'I am too afraid I will fall.' " The nurse should take which of the
following actions?
A. Notify the physician
B. Reassign the client to another nurse
C. Reexamine the nursing orders
D. Write a new nursing diagnosis - ANS :B. Reexamine the nursing orders
Rationale: The plan needs to be reassessed whenever goals are not met. Nursing
interventions should be examined to ensure the best interventions were selected to assist
the client achieve the goal. The goal may be appropriate, but the client may need more
time to achieve the desired outcome. The manner in which the nursing interventions were
implemented may have interfered with achieving the outcome.
In developing a plan of care for a client with chronic hypertension, which nursing activity
would be most important?
A. Set incremental goals for blood pressure reduction
B. Instruct the client to make dietary changes by reducing sodium intake
C. Include the client and family when setting goals and formulating the plan of care
D. Assess past compliance to medication regimens - ANS :C. Include the client and family
when setting goals and formulating the plan of care
Rationale: In developing a plan of care, nurses engage in a partnership with the client and
family. Nurses do not plan care for clients; instead they plan care with clients and families.
Assessment (option 4), goal setting (option 1), and interventions (option 2) will be most
accurate and effective when carried out in partnership with the client and family. The
other options represent other actions to take, but they will have less overall effectiveness if
the client and family are not part of the plan.
Which nurse is demonstrating the assessment phase of the nursing process?
A.The nurse who observes that the client's pain was relieved with pain medication
B. The nurse who turns the client to a more comfortable position
C. The nurse who ask the client how much lunch he or she ate
D. The nurse who works with the client to set desired outcome goals - ANS :C. The nurse
who ask the client how much lunch he or she ate
Rationale: Assessment involves collecting, organizing, validating, and documenting data
about a client. Option 1 represents the evaluation phase. Option 2 represents the
implemention phase. Option 4 represents the planning phase.
HALINTONE 2
, Comprehensive Predictor HESI PN Test
Bank
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that
this data is of which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANS :A. Subjective data from a primary source
Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse
interprets that this data is of which type and source?
The nurse feels a client is at risk for skin breakdown because he has only had clear liquids
for the last 10 days (and essentially no protein intake). The nurse would formulate which
diagnostic statement that would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANS :C. Risk for impaired skin integrity
related to malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human
response (impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2
do not have related factors that are under the control of the nurse (i.e., type of diet
ordered). The diagnosis in option 4 does not specify the type of impairment (greater than or
less than body requirements) and is therefore incomplete. It also does not provide direction
for development of goals and interventions.
The nurse would place which correctly written nursing diagnostic statement into the client's
care plan?
A. Cancer relater to cigarette smoking
B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen
saturation of 91%
C. Imbalance nutrition: more than body requirement related to overweight status
D. Impaired physical mobility related to generalized weakness and pain - ANS :B. Impaired
gas exchange related to aspiration of foreign matter as evidence by oxygen saturation of
91%
Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the
human response) names/labels the problem. The second part (related factors) includes the
HALINTONE 3
, Comprehensive Predictor HESI PN Test
Bank
factors that either contribute to or are probable etiologies of the human response. Some
formats include a third part to the statement for actual (not risk) diagnoses; this third part
consists of the client's signs or symptoms and is joined to the statement with the label as
evidenced by. This type of statement is the most complete. Option 1 is not a nursing
diagnosis but is a medical diagnosis. Options 3 and 4 are vague.
Which of the following outcome goals has the nurse designed correctly for the postoperative
client's plan of care? Select all that apply.
A. Client will state pain is less than or equal to 3 on zero to ten pain scale
B. Client will have no pain
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of
discharge
E. Client will be medicated every 4 hours by the nurse - ANS :C. Client will state pain is less
than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of
discharge
Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic,
and timely. Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve
the goal and are therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect
a postoperative client to be pain free. Option 5 is not a client goal.
The nurse questions if the dosage of a medication is unsafe for the client because of the
client's weight and age. The nurse should take which of the following actions?
A. Administer the medication as ordered by the prescriber
B. Call the prescriber to discuss the order and the nurse's concern
C. Administer the medication, but chart the nurse's concern about the dosage
D. Give the client half the dosage and document accordingly - ANS :B. Call the prescriber to
discuss the order and the nurse's concern
Rationale: Client safety is of the utmost importance when implementing any nursing
intervention. If the nurse feels that an order is unsafe or inappropriate for a client, the
nurse must act as a client advocate and collaborate with the appropriate healthcare team
member to determine the rationale for the order and/or modify the order as necessary. A
nurse accepts accountability for his or her actions. Options 1, 3, and 4 are inappropriate
and unsafe.
Which activity would be appropriate for the nurse to delegate to an unlicensed assistive
person (UAP)?
HALINTONE 4
