HESI Exit Exam 3 Graded A+ 2025

1. in administer nystatin suspension to the gum’s infant with candida infection. which approach should the PN use? Use glove finger to rub the suspension over the infected area. 2. the practical nurse (PN) is assessing with the pain of care for a client pain of care receiving the non-steroid anti-inflammatory drug for painful muscle spine of the back. which intervention should the PN include in the client plan of care? Assess the skin daily for area of ecchymosis or other signs of bleeding. 3. prior to giving the digoxin the PN assess that a two-month-old infant heart rate is 120bpm based on this finding what action should the PN take? give the medication and document the heart rate. 4. immediately after birth which nursing intervention has the highest priority for the newborn infant? preventing heart loss and neonatal cold stress. 5. A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contraction every 5 mins the PN monitors the client for 0ne hour using an external fetal monitor and determine that the client contractions are 7-15 mins apart lasting to 20-30 seconds with mild intensity by palpation. which action should the nurse take? send the client home and instruct to call the clinic when her contraction occurred 5 mins apart for one hour. 6. the online UAP report to the PN that an older client has a radius pulse of 55 bpm. which intervention should the PN implement first? obtain a full minute apical pulse assessment. 7. an older client who has a cologne resection 8 days ago is straining at stool the PN nurse observed sudden spillage of serosanguinous drainage from the client's wound followed by appearance bowel on the skin. which implication has occurred? Dehiscence 8. at 0800, a client apical pulse rate is 98 bpm 4 hours later the apical pulse is 54 bpm which action should the PN take next. determine the level of consciousness. 9. a charge nurse brings a #18 urinal catheter with 30 mL balloon to the PN who is preparing to insert a catheter in female client who weighs 50kg. which action do the PN takes first? consult with the charge nurse about the catheter. 10. the PN obtain a fingerstick glucose for a client with type one mellitus who is conscious and demonstrating hand tremors and shaking. the PN reports the client result of 55mg/dL to the nurse. which action should the PN prepare to implement next? provide the client a glass of milk. 11. the client with acute kidney injury is admitted with elevated pulse rate and blood pressure. which intervention should the PN implement? measure and document urinary output. 12. while changing the dressing of client who is immobile. the PN observes a red and swollen wound with moderate amount of yellow and green drainage and foul odor. before reporting this finding to the HCP, the PN should evaluate which client lab value? Culture for sensitive organism. 13. a client with hypertension complains of persistence dry cough the PN should tell the client that this a common side effect of which daily medication? Quinapril. 14. when gathering data about a client with dark skin tone which site should the PN observed? Sclera and mucous membrane. 15. a client who is receiving chemotherapy has developed stomate which instruction should the PN provides the UAP who is assessing with this client? provide gentle and meticulous care. 16. the PN views the midline a episiotomy of client who reports pain in her stitches. which action should the PN take first? observe suture line for separation and hematoma formation 17. client receiving an epidural anesthesia during labor. which observation is the most important adverse effect that the PN assess for following the administration of the epidural? maternal hypotension. 18. a client is using an intensive spirometer on the first postoperative day after inguinal herniorrhaphy. the PN should research the proper use of the spirometer when the client demonstrates which action? blowing forcefully into the mouthpiece. 19. the PN is preparing to assist an elderly client to the bathroom. the PN knows that an elderly adult center of gravity change from the... another area of the body. in planning to safely assist this client the PN knows that the center of gravity for the elderly client is in which area of the body? upper extremities. 20. the PN explains to a client hoe to obtain a septum specimen and the client indicate understanding the procedure after the PN leaves the room the client obtains the specimen and notifies the PN. when the PN arrives to collect it appears as seen in the picture what action should the PN takes. the PN should teach the client to a client how to obtain a septum specimen and if the client does not correctly collect the specimen the PN should assist the client in obtaining another specimen coughed directly into a sterile cup. 21. an adult client is undergoing weekly external radiation treatment breast cancer. upon arriving at the outpatient clinic for a schedule treatment the client reports increasing fatigue the PN who is taking the client vital signs what action should the PN implement? reinforced the need for extra test. plenty of sleep. 22. while changing a client postoperative dressing the PN observes red and swollen wound with a moderate amount of yellow and green drainage and foul odor positive resistances MRSA which is the most important action the PN to take. limit visitors to immediate family only 23. before administering zolpidem at bedtime which client assessment should the PN complete? mental status. 24. picture: the Pn assess a child in 90-90 skeletal traction it is most important for the PN to assess the signs of inflammation at what location (select the correct location of the image) q33. 25. a client is diagnosis with hyperthyroidism which symptoms should the PN expect this client to exhibit? muscle cramping and dry, flush skin. 26. PN administered antibiotic to a client with respiratory tract infection to evaluate the medication effectiveness which lab values should the PN monitor? -sputum culture and sensitivity -white cells blood count 27. the PN is calling for a client whose drug screen is positive for cocaine which behavior should the PN document as evidence as withdrawal? intense craving. 28. the PN is observing a newly hired UAP bathing a client who has a type2 DA the UAP place the client feet in the wash basin filled with warm soapy water to soak which action should the PN take. check the client feet before sucking 29. the PN is assessing the recreational director of a long-term care facility plan outdoor activities for the wheelchair bound older client mentally alert which activity meets the physical needs of this resident. a tea party in the courtyard. 30. which assessment findings indicate to the PN that venturi face mask is producing the desire effect. increase oxygen saturation. 31. a client who has a history of asthma expressing concern about rapidly spreading flu like diseases in the community which instruction should the PN provide. obtain an influenza vaccine. 32. prior to discharge a new mother who is breastfeeding tell the PN about breast that are now hard shine and warm which action should the PN take. develop a schedule increasing the time intervals between feedings. 33. the PN enters the room of client who underwent mastectomy 8 hours ago the PN observes The UAP preparing. instruct the UAP to measure the client BP on the non-cooperative side. 34. the PN assigning care of a group of on biology medical unit care which client care intervention should the PN assign to UAP. empty bedside drainage with indwelling catheter transport urine culture sample to the lab. 35. the PN is assisting the client to the bathroom after right cataract extraction the client has an eye shield over the right eye how should. stand in front of the client and lead the client to the bathroom. 36. which client information is the most important for the PN to consider after providing instruction to the UAP about providing morning care to the postoperative client. urinary output 50 mL/h. 37. an older client male resident of a long-term facility is at woke at 3;30 am wandering down hallway with pajamas unbutton which intervention the PN implement. address the client to determine his needs. 38. the client receives acetaminophen prior to chemotherapy treatment how should the PN evaluate the effectiveness of the medication. monitor the client for nausea and vomiting following the treatment. 39. the male client with TB returns to clinic for the daily antibiotics injections the client has been taking antitubercular medication for 12 weeks and ...he has ringing in the ears which prescribed medication should the PN report to HCP. Gentamicin 160 mg daily. 40. a young adult female client a mother with 2 small children looks different and depressed ... after learning HCP that she has a MULTIPLE SCLESSIS which nursing intervention should the PN implement immediately after the client has been diagnosis. sit quietly with the client and answer questions she may ask. 41. the PN is caring for hospice client who request a priest for the last right which should be the next response by the PN? offer to contact the priest for the client. 42. in which client situation should PN assess the presence of Cheyne strokes respiration. when death is intermittent. 43. the PN receives change of shift report of postpartum which client should receive the PN attention first? A client who needs to ambulate to the bathroom for the first time since the birth of her infant. 44. The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following affecting the right hemisphere. Which action should the PN implement? Demonstrate to the UAP how to approach the client from the client's left side. 45. Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply) -Time of last administration of pain medication -Effectiveness of last pain medication administered. -Client's pain rating on a scale of 1 to 10. 46. The practical nurse (PN) notes that the client has truncal obesity, a moon face, and a buffalo hump. The PN should question clients about recent use of which type of medication? Thyroid replacement hormone. 47. The practical nurse (PN) observes unlicensed assistive personnel (AUP) who is leaving a client's room with visibility and solid hands. Which immediate action should the PN take? Advice the UAP to wash hands before providing further care. 48. The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first? A preschooler who had an emergency appendectomy for appendicitis. 49. A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the practical nurse (PN) identifies those unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missing component, which action should the PN take? Supervise the UAP after reviewing the protocol. 50. Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis? I've found the support I need from my faith and family. 51. A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) included in the assessment of this client? What are the voices uttering? 52. A client is voiding frequent small amounts 24-hours-following the removal of an indwelling catheter, and a post-voided residual prescribed. What explanation should the practical nurse (PN) provide to the client about why the procedure is necessary? The catheterized volume determines the need to re-insert the indwelling catheter. 53. An oil retention enema is prescribed for a hospitalized client. The practical nurse (PN) should administer the enema solution at which temperature? The solution should approximate the client's body temperature (98 F or 36 C). 54. The healthcare provider tells the family of a 6-year-old child with a malignant brain tumor that the tumor is metastasizing and the child's conduction to the terminal. How can the practical nurse (PN) best help the family cope with this news? Listen to the family's reactions and reflect on their fears and concerns. 55. The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief painful procedure. Which action should the PN implement during the procedure? Encourage the client to reminisce about a favorite past family event. 56. The healthcare provider prescribed aliskiren 225 mg PO daily for a client with the diagnosis of hypertension. The pharmacy provides 150 mg scored tablets. How many tablets should the practical nurse (PN) administer to the client? (Enter numerical value only. If rounding is required, round to the nearest tenth). 1.5. 57. A client with unstable angina pectoris receives a prescription for nitroglycerin 0.4 mg sublingual PRN chest pain q5 minutes x3. The prescription includes leaving the medication at the bedside for self-administration. Which assessment finding should the practical nurse (PN) obtain first? Heart rate and blood pressure. 58. To obtain an estimate of a client's systolic blood pressure, what action should the practical nurse (PN) take first? Palpate the client's brachial pulse. 59. An older adult man who manages all his personal affairs is admitted to a long-term care facility because of mobility problems related to rheumatoid arthritis. When the practical nurse (PN) presents the client with a blank advanced directives form, he explains that he is not dying and not cognitively impaired and states he does not need to complete such a form. What action is most important for the PN to take? Acknowledge the client's concerns and notify the health care provider of the client's wishes. 60. The practical nurse (PN) is assisting with the care of an infant who was born 6 hours ago and is prescribed supplemental oxygen. Which action can the PN safely implement? Assess and record oxygen saturation levels every hour. 61. a married woman comes to a annual woman physical examination. during the interview with PN the client makes minimal eye contact. the PN observes yellow bruising to the lower eye and purple bruising on the client up arm which looks like fingerprints which question is the best for the PN to ask the client. is there something you want to tell me? 62. the PN is planning to ambulate a client who has been on bedside for 24 hours following a colon resection. to safely ambulate which intervention should the PN implement first? assist the client to a bed side sitting position. 63. a PN is caring for a client with coronary artery disease who is admitted with intermittent chest pain. the admission lab results indicate elevation in troponin 1 and creatinine phosphokinases myoglobin isoenzyme (CK-MB) levels. what should the PN consider the most significant risk for this client on the second of admission? the lab result indicates myocardial damage, and the client is at risk for cardiac dysrhythmias. 64. a client with fracture left hip is in buck traction which outcome should the PN expect the client to exhibit. the left foot is warm to touch with a palpable dorsalis pedis pulse. 65. a PN is assigned for 4 clients on the medical surgical unit ranked in order in which the PN should prioritized them -a client who is admitted with suspected raptured appendix -a client who is post lumbar puncture -an older male with AD -postoperative client 66. a client who is experiencing paralysis of the left arm curses at the PN and throws hairbrush against the wall using the right arm how should the PN response. offer to return later when the client is calmer. 67. a male client meal tray arrives on the nursing unit 30 mins late when the PN delivers the client express anger that his tray was late. how should the PN respond. apologize that the tray was late being delivered. 68. a client is receiving a continuous 1/2 strength tube feeding at 50 mL/h through gastrotomy tube after the feeding has been administered for 4 hours the PN check the gastric contents and obtains 100 ML. which action should the PN implement. plan to recheck the residual in one hour. 69. the PN is assigned to care for an elderly female client who refuses to eat while checking the client mouth the PN finds that the client dentures is fits poorly and several reddened areas in her mouth which food selection should the PN is appropriate to eat. ice cream or milk shake. 70. the HCP gives a pregnant prescription: -oatmeal is good choice for breakfast -add lentils and black beans to soup -increase green leaf veggies 71. an older female client is admitted syncope lab findings indicate that her Hb 8.0 g/dL she has a recent history of headaches and frequent falls admission orders includes which meds should the PN withholds .... charge nurse? Aspirin. 72. at 1200 PN teams that a client 0900 dose which action should the PN take? withhold a missed dose unless seizure activities occur. 73. while the PN and UAP are turning a client with abdomen incision eviscerate which task is best for the PN to assign to UAP. gather supplies. 74. the PN is caring for client who is experiencing a tonic colonic seizure what is the most important goal for this client. protect the client for injury. 75. based on the principles of asepsis the PN should consider which principle to sterile. an open sterile Foley catheter kit set up on the table at PN waist level. 76. an older male client returns to the clinic for follow up visit with the HCP for management of depression which findings indicates to PN that the client is improving. sleeps through the night often. 77. A male client takes one baby aspirin daily to prevent heart attack. He asks the practical nurse (PN) if this medication is safe to administer to his visiting eight-year-old grandchild who has developed a fever and sore throat. Which information should the PN provide? Explain that giving a prescribed medication to anyone else is not safe to practice. 78. The unlicensed assistive personnel (AUP) reports to the practical nurse (PN) that a resident of the long-term care facility being treated for a streptococcus pneumoniae infection has been coughing and has a fever/ When passing by the client's room the PN observes the UAP leaving the client's door open. What action should the PN take? Review droplet precautions with the UAP. 79. When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy. She becomes angry and yells at the PN "Get out of here I'll get up when I'm ready" Which response is best for the PN to make? I know you feel angry about the pain of the ambulation, but this is a necessary part of getting well. 80. Which location should the practical nurse palpate to determine if a client's submandibular lymph nodes are enlarged? Beneath the lower jaw. 81. The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the change nurse? Blood urea nitrogen 75 mg/Dl. 82. A male preoperative client who has already signed the informed consent for a surgical procedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take? Notify the charge nurse of the client's concerns about surgery. 83. The practical nurse (PN) enters the room of a client who is disoriented and has a wrist restaurant secured as seen in the picture. Which action should the PN take? Use a full knot to secure the restraint tie. 84. A client is admitted to the postoperative surgical unit with two chest tubes after a left lobectomy. The practical nurse (PN) observes that the water-sealed chambers are set at the prescribed suction of 20 cm water pressure, and tailing occurs with respirations and bubbling. What action should the PN implement? Maintain system integrity to promote lung re-expansion. 85. An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take? remind the client what day of the week it is. 86. The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse (PN) recommend? Cotton. 87. The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a lens kin headache. Which action should the PN take? Explain that medication can only be provided to clients. 88. In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement? Instruct the mother to play with the child for stimulation and distraction. 89. Unlicensed assistive personnel (UAP) is assisting with the care of a client with a peripherally inserted central venous catheter (PNCC). What guidance should the practical nurse (PN) provide to the UAP? Use the opposite arm for blood pressure measurement. 90. Based on the nursing diagnosis of, "Risk for infection." Which intervention should the practical nurse