HESI PN CASE STUDIES Exam Questions and Answers Verified 100% Correct

HESI PN CASE STUDIES Exam Questions and Answers Verified 100% Correct An older male client tells the practical nurse (PN) that his religion does not permit him to bathe daily. How should the PN respond? - ANSWER -Request that the client clarify his religious beliefs about bathing. Rationale A client's religious and cultural preferences should be considered when providing basic hygiene. The client's religious beliefs should be considered in the client's choice so gathering further information about the client's self care practices is important. A client who has a pressure-relieving mattress overlay is mobilized to a chair and imprints of the client's buttocks, heels, and scapula are evident on the mattress overlay. What action should the practical nurse implement? - ANSWER -Apply a different pressure-relieving device and assess its effectiveness for this client. Rationale The deeper the indent or imprint of the body left in the mattress, the more compressed, the harder the surface, and the less supportive it is for the client. Bottoming out, as evidenced by the deep imprints in the mattress overlay, indicates that this device is not indicated for this client and a different device or strategy should be implemented to prevent pressure ulcer formation. The practical nurse (PN) identifies several findings in an older client who is on prolonged bed rest. Which finding requires prompt action by the PN? - ANSWER -Bowel movements decrease to one every third day. Rationale Immobility reduces venous return, appetite, fluid intake, and peristalsis, which reduces the frequency of bowel movements and increases the risk for constipation and impaction, which requires prompt intervention. What position should the practical nurse (PN) place a client in who is receiving an enteral tube feeding? - ANSWER -Supine with the head of the bed elevated 30 to 45 degrees. The practical nurse (PN) is obtaining the vital signs for a client who has a urinary tract infection with methicillin-resistant Staphylococcus aureus (MRSA). How should the PN proceed? - ANSWER -Don a gown and gloves before entering the room. Rationale MRSA in the urinary tract requires contact isolation, which includes the use of a gown and gloves. In addition to gloves and a disposable stethoscope, a gown should be worn to avoid potential contact with MRSA-contaminated environmental surfaces while taking vital signs. Although antiseptic wipes may be helpful if disposables are not available, bedside equipment used for the client with MRSA should remain in the room. Since the infection is in the urinary tract, not the respiratory system, a mask is not indicated while taking vital signs. When irrigating the external ear canals of an older adult client, which action should the practical nurse (PN) use to soften dry cerumen for removal? - ANSWER -Instill mineral oil in the external auditory canal overnight before irrigation. Rationale Mineral oil should be placed in the external auditory canal overnight to soften dry, impacted cerumen and facilitate removal. Warming the solution and using a 50 ml syringe can be implemented after the cerumen is softened for removal. Which intervention provides confirmation of nasogastric tube (NGT) placement before NGT feedings are started? - ANSWER -Flat plate xray of the abdomen. Rationale An x-ray is the most accurate confirmation method of NGT placement and should be done before formula feedings are initiated. A client whose diet is low in fiber is at risk for which condition? - ANSWER Colon cancer. Rationale Fiber speeds the movement of substances through the GI tract, reducing the amount of time the colon absorbs water and its exposure to digestive end-products