HESI PN Comprehensive Exam 2 with complete solution(This exam consists of frequently tested questions and answers latest 2021)

HESI PN Comprehensive Exam 2 with complete solution(This exam consists of frequently tested questions and answers latest 2021) A newborn with apnea is being discharged from the hospital with home monitoring. What information concerning the infa t's care should the practical nurse review with the parents? A newborn with apnea is being discharged from the hospital with home monitoring. What information concerning the infant's care should the practical nurse review with the parents? A. Cardiopulmonary resuscitation (CPR). B. Administration of intravenous antibiotics. C. Reassurance that the infant cannot be electrocuted during monitoring. D. Advise that the infant not be left with caretakers, such as babysitters. Correct answer- A. Cardiopulmonary resuscitation (CPR). Rationale: Apnea of infancy (AOI) engenders great anxiety in parents, and the initiation of home monitoring presents additional emotional stress. When home monitoring is required the parents should receive instructions that include cardiopulmonary resuscitation(A). (B) does not indicate Apnea Which protocol regarding standard policies about prescriptions should the practical nurse (PN) question? A. All drug prescriptions should have the date, time, and prescriber's signature. B.Verbal orders are accepted from prescribers and should include signatures. C. Prescribers may write specific times at which the medications are to be given. D. Preoperative prescriptions should be resumed after a client returns from surgery Correct answer- D. Preoperative prescriptions should be resumed after a client returns from surgery. Rationale: A standard policy about preoperative medications that preoperative prescriptions are automatically canceled for surgery and should be rewritten, if indicated , in the postoperatively so the (PN) should question (D). (A,B,C) are correct statements. When reviewing the safety precautions regarding newborns, what information should the practical nurse communicate to the parents? A. Position the infant to sleep on the baby's back. B. Use a crib with slats no more than 4 inches apart. C. Propping a bottle can be done when the infant gets older. D. Place the infant a front-facing car seat in the automobile. Correct answer- A. Position the infant to sleep on the baby's back. Rationale: The incident of sudden infant death syndrome (SIDS) decline when infants are positioned on their backs (A), instead of prone for sleeping. Crib slats (B) 2.375 inches apart to prevent the baby from slipping. (C) Never prop a babies bottle. (D)Infant who weighs less than 30lbs should be placed in a rear facing car seat. When monitoring a newborn, which observation should the practical nurse report to the healthcare provider? A. Rectal temperature of 37.6° C. B. Axillary temperature of 37.1° C. C. Heart rate of 110 beats per minute. Correct D. Respiration rate of 40 breaths per minute. Correct answer- C. Heart rate of 110 beats per minute Rationale: The normal range for a heart beat for an infant is 120-160 so a heart rate of 110 should be reported to the healthcare provider. Newborn temperature ranges from 97.7,99.4,36.5,37.5 and normal respiratory rate is 30-60 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? A. "I will avoid taking any products with acetaminophen, such as Tylenol." B. "I will eliminate alcohol consumption until my infection subsides." C. "I should eat a diet rich in dark green leafy vegetables." D. "I understand that my other medications doses need to be increased." Correct answer- A. "I will avoid taking any products with acetaminophen, such as Tylenol." Rationale: Tylenol is metabolized in the liver and should be avoided with clients with liver disease 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? A. Remove the child's finger rings. B. Assess and document the child's level of pain. C. Evaluate the child's range of motion. D. Place arm in a sling at level of the child's heart. Correct answer- A. Remove the child's finger rings. Rationale: The child is a 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 The practical nurse (PN) is participating in a group interview of an applicant who will work in the clinic as a staff PN. Which question is best to ask the applicant? A. "This position requires working on-call every fourth weekend. Can you do that?" B. "Do you have child care arrangements for your children?" C. "Do you have any religious requirements that need scheduling accommodation?" D. "Are you going to be the sole supporter for your family?" Correct answer- A. "This position requires working on-call every fourth weekend. Can you do that?" Rationale: Job interview questions must be specifically job related (A) 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? A. Encourage UAP to deal with it privately to prevent compromising client confidentiality. B. Offer a group discussion session so staff can share their thoughts and feelings. C. Invite staff out after hours to help distract them from the disturbing client event. D. Refer the UAP to human resources department for a counseling session with a therapist. Correct answer- B.Offer a group discussion session so staff can share their thoughts and feelings Rationale: A critical incident stress debriefing evolves 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 A group of practical nurses (PNs) who work on a medical-surgical unit believe they are understaffed. Which data should the PNs consider when preparing the justification for additional staff? A. Staffing ratios in other states. B. Client acuity and census. C. Overtime payment and unfilled positions. D. Number and frequency of client complaints. Correct answer- B. Client acuity and census. Rationale: When presenting the need for increased staff, the PNs should present the request using staffing guidelines that consider client acuity, number of clients, and length of stay(B). The practical nurse (PN) assigns care of a client who is HIV positive to a newly employed PN who states, I can't take care of that client. How should the PN respond? A. "I don't understand your response. Please explain what you mean." B. "Staff cannot pick and choose assignments based on a client's diagnosis." C. "This client will provide a learning opportunity for you, and I'm here to help." D. "I will give you a different client so you will be more comfortable." Correct answer- A. "I don't understand your response. Please explain what you mean." Rationale: The ethical principle of beneficence guides decisions based on the clients well being or dignity. The PN should first assess the rationale supporting the response (A) which may include an infection such as a "Cold" that places the immunosuppressed client at risk A client with type 2 diabetes mellitus is admitted to the hospital for an exacerbation of asthma. The practical nurse (PN) administers hydrocortisone (Solu-Cortef) 60 mg PO every 6 hours. What information should the PN to review the next day? A. Serum potassium. B. Serum glucose. C. Respiratory rate. D. Blood pressure. Correct answer- B. Serum glucose. Rationale: High doses of glucocorticoidsteriods can cause an elevation in the serum glucose level, so the PN should review the clients serum glucose(B) Which information should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP) who is newly assigned to the unit? A. Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. B. Determine if pain subsides 20 minutes after a client receives an injection. C. Report signs of infection in urine that collects in a bedside drainage unit. D. Observe how clients are using an incentive spirometer after surgery. Correct answer- A. Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. Rationale: Information about the basic care clients such as positioning (A) should be specific to a common intervention or treatment and should focus on task within the scope of the UAP's assignment A woman who is 32-weeks gestation arrives at the prenatal clinic and reports painless contractions and mucoid vaginal discharge. The fetal heart rate is 150 beats/minutes. What action should the practical nurse (PN) implement first? A. Place in the left lateral recumbent position. B. Ask about recent sexual intercourse. C. Encourage an increase in oral fluid intake. D. Determine when the contractions began. Correct answer- A. Place in the left lateral recumbent position. Rationale: Preterm labors symptoms include contractions and mucoid vaginal discharge so the PN should place the client in the left lateral position A 14-year-old female arrives in the school nurse's office seeking information about healthcare agencies in the community. The practical nurse (PN) understands the client can make an autonomous healthcare decision if she has which circumstance? A. Pregnancy. B. Funds to pay for her own care. C. Homelessness. D. A life-threatening condition. Correct answer- A. Pregnancy. Rationale: According to the supreme court a minor who is pregnant (A) can make an autonomous healthcare decision The practical nurse (PN) stops to help an unconscious victim at the site of a motor vehicle collision. After Emergency Medical Services (EMS) arrive, the PN reports that first aid was rendered and then leaves. The victim dies on the scene from the injuries sustained. What is the PN's liability? A. Criminal assault and battery. B. Negligent acts of omission. C. Good Samaritan immunity. D. Client abandonment. Correct answer- C. Good Samaritan immunity. Rationale: Based on the good Samaritan act (C) the PN rendered emergency care in good faith at the scene of the accident and is immune from civil liability for actions while providing care. The PN did not violate the status of Nurse practice act A child is admitted for severe abdominal pain and possible appendicitis. Laboratory and x-ray studies are prescribed. During the diagnostic period, the practical nurse should implement which nursing actions? (Check all that apply.) A. Maintain child's comfort. B. Relieve parent and child's anxiety. C. Prepare for surgery. D. Give oral home medications. E. Encourage ambulation. Correct answer- A. Maintain child's comfort. B. Relieve parent and child's anxiety. C. Prepare for surgery. 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)? A. Determine the gastric residual's pH before starting the feeding at prescribed rate. B. Obtain stool specimen for culture of diarrhea stool that occurred after first feeding. C. Discards 60 ml of gastric residual before giving formula. D. Give 30 ml of tap water after administration of formula. Correct answer- D. Give 30 ml of tap water after administration of formula. Rationale: After administering formula additional water should be given to prevent obstruction of the GT and provide the client with additional hydration A client is being discharged after repair of a retinal detachment. The practical nurse (PN) reviews the written discharge information with the client and family. Which instruction should the PN emphasize to the client when arriving at home? A. Limit reading or writing for 3 weeks. B. Take a PRN antiemetic with early signs of nausea. C. Keep the head flat and centered when lying down. D. Self administer eye medications. Correct answer- B. Take a PRN antiemetic with early signs of nausea. Rationale: To minimize increased intraocular pressure, it is most important that the client take an antiemetic as soon as nausea is experienced (B) to prevent vomiting that can cause displacement of the retinal repair A male client is eating at his bedside table and suddenly starts gagging, is unable to talk, and places both hands over his throat. Which action should the practical nurse implement? A. Provide manual ventilation with a mask bag. B. Give five back blows or slaps. C. Use a blind finger sweep inside the mouth. D. Apply successive abdominal thrusts. Correct answer- D. Apply successive abdominal thrusts. Rationale: Abdominal thrusts, also known as the Heimlich maneuver (D), should be performed to loosen the obstructing foreign body. The client's airway is obstructed and (A) is ineffective. Back blows (B) and a blind finger sweep of the mouth (C) are not recommended actions for obstructed airway The practical nurse (PN) observes a family member accidentally stumble over the three-compartment drainage system (Pleur-evac®) for a client with a chest tube to suction. The PN sees that the drainage system container is cracked and the chest tube is disconnected. What action should the PN implement? A. Cover the end of the chest tube with a sterile gloved hand. B. Submerge the end of the chest tube in a bottle of sterile water. C. Fill the water-seal chamber in the chest drainage container. D. Cover chest tube site with petroleum-based impregnated gauze. Correct answer- B. Submerge the end of the chest tube in a bottle of sterile water Rationale: The disconnected chest tube allows air into the chest cavity, which causes pneumothorax. The water seal should be reestablished by quickly placing the end of the tube in a bottle of sterile water (B) until a new apparatus can be prepared. A gloved hand (A) cannot create a sufficient seal against air entering the pleural space. (C) is not indicated. (D) is indicated if the chest tube dislodges from the chest, not the drainage system container The PN is preparing to administer azithromycin (Zithromax) 500 mg PO for a client with pneumonia. The medication is available as a suspension that is labeled, "200 mg/5 mL." How many mL should the PN administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) Correct answer- Answer: 12.5 A female client recently diagnosed with colon cancer is admitted for surgery. When the practical nurse (PN) asks the woman how she is feeling, the client starts to cry. How should the PN respond? A. Sit in silence with the client as she cries. B. Leave her alone to provide privacy. C. Remind her that early surgery can be a cure. D. Ask a chaplain to come see the client. Correct answer- A. Sit in silence with the client as she cries. Rationale: Sitting down with the client in silence (A) is an effective form of therapeutic communication that allows the client to express herself with tears. Since the client has not asked to be left alone, (B) may be interpreted as abandonment. The client should be allowed to grieve without false reassurance (C). (D) should be implemented in response to a client's request. 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. A female client with dysuria and urinalysis reveals presence of 3 to 5 white blood cells. B. Male client with Hepatitis B exposure has positive serum results for Hepatitis B core antibody. C. An older client who has received heparin for two weeks with a platelet count of 15,500/mm3. D. A young adult with rhinorrhea and common cold with an eosinophils count of 20%. Correct answer- C. 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 Which observation by the practical nurse (PN) indicates that a piece of medical equipment is not functioning properly? A. The digital bedside glucose meter displays the word HI. B. A pulse oximeter indicates it is unable to detect a pulse. C. The bed alarm sounds an audible alarm when client sits up. D. The sphygmomanometer's reading drops without a knob turn. Correct answer- D. The sphygmomanometer's reading drops without a knob turn. Rationale: The blood pressure reading that is not controlled by the knob (D) on the cuff indicates a malfunction of the equipment. (A) is a function that is set by the manufacturer to indicate an extremely elevated blood sugar. A pulse oximeter does not display (B). (C) is a function that warns the staff that a client is attempting to get out of bed without assistance. Which finding in a 4-month-old infant warrants further investigation by the practical nurse? A. Wets 8 diapers a day. B. Grunts with expiration. C. Protruding abdomen. D. Inability to sit up without support. Correct answer- B. 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. After a community disaster, two clients must be placed in the same room. Which client should the practical nurse select for placement in a room with a client with systemic lupus erythematosus (SLE)? A. An 80-year-old client with diabetes mellitus and pneumonia. B. A client with a productive cough with yellow phlegm. C. A client scheduled for an emergency appendectomy. D. A 20-year-old with the diagnoses of Neisseria meningitis. Correct answer- C. A client scheduled for an emergency appendectomy. Rationale: A client with SLE is immunosuppressed and is susceptible to infections, so the client with appendicitis (C), which is an intra-abdominal inflammation of the appendix, is the best option to place in the same room. A client with an infectious or contagious disease (A, B, and D) should not be in the same room with a client with SLE. The practical nurse is assisting with moving clients into semiprivate rooms so other rooms can be made available for the admission of victims of a community disaster. Which two clients should be placed in the same room? A. Two clients on contact precautions for skin and wound infections caused by different bacteria. B. A toddler with Rubeola measles and an infant with bacterial pneumonia. C. One client in airborne precautions and another client in droplet precautions. D. Two clients on universal precautions, one for asthma exacerbation, the other with heart failure. Correct answer- D. Two clients on universal precautions, one for asthma exacerbation, the other with heart failure. Rationale: Two non-infectious clients on universal precautions should be placed in the same room (D). (A, B, and C) are susceptible to nosocomial transmission of each others' infectious agent. The practical nurse (PN) arrives at the scene of a mass casualty community disaster. Which victim should the PN triage for immediate transport to the hospital for additional care? A. Older male with an obvious arm deformity who did not take his medicine today. B. Woman who is 8-months pregnant with multiple facial lacerations. C. Preschooler who is complaining of ear pain and has yellow nasal discharge. D. An adolescent male with mouth burns and singed nasal hairs. Correct answer- D. An adolescent male with mouth burns and singed nasal hairs. Rationale: The victim with singed nasal hairs (D) has inhaled flames or hot smoke and is at risk for swelling of the airways, which requires preemptive intubation to avert an expected possible life-threatening respiratory closure and arrest. (A) can be transported about the possible closed fracture site is splinted. (B) is not manifesting signs of impending delivery, and lacerations can be repaired up to 12 hours after the injury. (C) is not a priority for immediate transport. A healthcare provider begins screaming at the practical nurse (PN) who is standing at the nurses' station and demands that the laboratory results be made available immediately. Which action should the PN take first? A. Suggest moving to a private area to discuss further. B. Complete an incident report about unprofessional behaviors. C. Request that the laboratory send the reports immediately. D. Call the nursing supervisor to intervene in the situation. Correct answer- A. Suggest moving to a private area to discuss further. Rationale: Moving to a private area to discuss the issues away from public display is the first action (A), which may help de-escalate the situation. (B) may be indicated after the nursing supervisor is called to assist with resolving the incident. Although (C) is indicated, a setting that provides privacy should be used first to minimizing further disruptive interaction. The nursing supervisor (D) should be called to assist with the situation but privacy for further discussion should be suggested first The practical nurse (PN) is assigned to assist with receiving clients in the Emergency Department (ED) following a community disaster. Which client finding should the PN recognize as the highest priority for care? A. Fractured femur and the client cannot move either leg. B. Sucking chest wound with protruding glass shard in chest. C. Full-thickness burns over 50% of the client's body. D. A woman with vaginal spotting who is 16-weeks gestation. Correct answer- B. Sucking chest wound with protruding glass shard in chest Rationale: In any disaster, an immediate threat to life is the priority. The highest priority client is oxygenation, so the client with a sucking chest wound should receive immediate care. The care of the other clients (A, C, and D) should be imminently given, but do not have the priority of (B). A female client who is waiting for the results of her breast biopsy tells the practical nurse (PN) that she fears it is cancer. How should the PN respond? A. "I understand how you feel." B. "I am sure everything will be fine." C. "This must be a difficult time for you." D. "They are finding new cures every day." Correct answer- C. "This must be a difficult time for you." Rationale: The PN should acknowledge the client's feelings (C). Although this respond attempts to express empathy, unless the nurse has had the same experience, (A) may not be perceived as supportive. (B) offers false reassurance. (D) ignores the client's feeling and closes the topic Which individual should the practical nurse (PN) respond to first? A. A visitor is lying still on the floor in the middle of the unit hallway. B. The nursing supervisor is waiting to talk with the PN on the phone. C. An unlicensed assistive personnel who reports a sink is leaking water on the floor. D. A postoperative client who is requesting medication for pain that is 10 (0-10 scale). Correct answer- A. 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. 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? A. Evaluate the client's ventilatory effort against the ventilator. B. Check the ventilator pressure settings. C. Inspect the trachea to see if it is midline. D. Determine if an emergency thoracotomy tray is available. Correct answer- C. 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 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? A. Ripping chest pain and blood pressures of 150/90 in right arm and 120/70 in left arm. B. Sudden right flank pain with gross hematuria. C. Sharp epigastric pain that radiates to the scapula. D. Lower back pain that radiates down back of the leg and is more intense with coughing. Correct answer- A. 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 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? A. Prevent emboli. B. Stop plaque buildup. C. Dissolve blood clots. D. Control heart rhythm. Correct answer- A. 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). What finding is most important for the practical nurse to consider before ambulating an older client? A. Length of intravenous tubing. B. History of Alzheimer's disease. C. Use of assistive devices. D. Time the client last voided. Correct answer- C. Use of assistive devices. Rationale: To ensure the client's safety, it is most important to determine if any assistive devices are needed prior to ambulation (C). Although (A, B, and D) provide useful information, they do not have the importance of (C). The practical nurse (PN) is caring for a client who is receiving chemotherapy for cervical cancer who is scheduled to go for a chest xray. Current laboratory results include hemoglobin 10.0 grams/dl, absolute neutrophil count (ANC) of 500, platelets 120,000/mm3, and white blood cells 4,000/mm3. What action should the PN implement first? A. Notify healthcare provider about laboratory results. B. Compare client's results with past laboratory values. C. Examine the client for the presence of ecchymosis. D. Place a protective mask on the client for transport. Correct answer- D. Place a protective mask on the client for transport.