HESI LPN Comprehensive Exit Exam Updated Latest 2024

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. - 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 - 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. - 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. - 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." - 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. - 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?" - 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. - 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. - 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." - 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. - 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. - 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. - 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. - 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. - 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. - 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. - 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. - 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. - 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. - 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.) - 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. - 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%. - 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. - 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. - 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. - 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. - 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. - 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. - 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. - 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." - 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). - 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. - 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. - 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. - 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. - 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. - D. Place a protective mask on the client for transport. Rationale: The client is immunosuppressed due to a side effect of chemotherapy, as evidenced by the client's ANC (which is calculated daily using # WBC x % neutrophils). If the ANC is less than 1,000, protective precautions (reverse isolation) is indicated, so the PN should place a protective mask on the client for transport to xray (D). (A, B, and C) are implemented after (D). The practical nurse (PN) enters a client's room at 0900 to administer a heparin injection that is prescribed BID. The physical therapist is in the middle of providing bedside therapy. What action should the PN take? A. Ask the therapist to stop and step out for the medication administration. B. Administer medication while the therapist continues the therapy. C. Leave with the medication and come back after the therapist is finished. D. Take the injection and administer it at the next administration time. - C. Leave with the medication and come back after the therapist is finished. Rationale: Since the heparin injection does not require immediate administration, the best action is to allow the professional colleague to finish the therapy session and then return to give the medication within the allowed hour after the scheduled time (C). Interrupting the therapy session (A) does not respect the importance of the therapist's role in the client's care. It is not necessary to administer two non- emergent therapies at the same time (B). (D) omits one of the prescribed dosages An older client who takes digoxin (Lanoxin) daily calls the clinic about not feeling well. The new onset of which finding should the practical nurse advise the client to come for a visit with the healthcare provider? A. Vomiting. B. Tachycardia. C. Constipation. D. Tinnitus. - A. Vomiting. Rationale: In older clients, nausea and vomiting (A) are early signs of digoxin toxicity, which can occur due to cumulative effects, even with subtoxic digoxin levels. Bradycardia, not tachycardia (B) is a sign of digoxin toxicity. Constipation (C) is not related to digoxin toxicity. Tinnitus (D) is a symptom of aspirin toxicity. An older male client with a history of hypertension presents in the urgent care center with an elevated blood pressure and tachycardia. Which finding should the practical nurse report to the healthcare provider immediately? A. Tearing pain that has moved to his low back. B. Sharp sensation with deep breath. C. Pain elicited upon palpation. D. Pain level at 10 (0-10 scale). - A. Tearing pain that has moved to his low back. Rationale: The client has classic findings, such as age and history of hypertension, for a possible dissecting aneurysm. Severe tearing pain that moves from the client's chest to the back (A) is symptomatic of this life threatening and requires immediate treatment and must be reported immediately. (B and C) are not consistent with a dissecting aneurysm. Since other benign conditions can cause severe pain, the severity of the pain (D), in and of itself, is not the most important finding. 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? A. Perform a head-tilt, chin-lift maneuver when spinal trauma is suspected. B. Place the mask over nose and mouth using a c-e one-hand technique. C. Measure the mask size from the supraorbital rim to the mandible tip. D. Position a rolled-up towel under the head to aid positioning of the airway. - B. 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 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? A. Report the findings to the charge nurse. B. Tell the client to remain on bedrest. C. Obtain the client's pulse oximetry reading. D. Call the rapid response team. - A. 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 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? A. Review the client's white blood cell count. B. Ask if she has recently traveled to foreign country. C. Collect a stool sample for culture for C. difficile. D. Obtain her vital signs lying and standing. - D. 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 implemented 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 determined first to provide safe care. A male child who hit his face on the sidewalk after falling off his bike presents in the school nurse's office with noticeable swelling around the mouth and nose and is carrying his front teeth in a tissue. Which action should the practical nurse (PN) take first? A. Call the parent for permission to treat. B. Obtain the respiratory rate and effort. C. Place the teeth in a cup of sterile water. D. Assess the level of pain and apply ice. - B. Obtain the respiratory rate and effort. Rationale: Adequacy of breathing (B) is always an initial priority, especially with facial trauma and swelling (B), which could cause aspiration of a tooth. (A, C, and D) should be implemented after ensuring the child airway is open and his breathing is stable The practical nurse (PN) is caring for a client in a weight reduction program. Which client behavior is the best indicator to the PN that the client is applying the knowledge gained from the program about weight loss? A. Requests a diet brochure to read. B. Lists correctly foods high in fat. C. Discusses feelings about dieting. D. Loses five pounds in three weeks. - D. Loses five pounds in three weeks. Rationale: A change in behavior with measurable results, such as 5 pound weight loss in 3 weeks (D) is the best indicator of the client's application of the weight loss program. The client may not read or apply the information in the brochure (A). Knowledge of high fat foods does not ensure the client's application of modifying the diet (B). Discussing feelings (C) may assist the client to apply the weight reduction program, but the best evaluation of participation in the program is the client's weight loss A client who is 39-weeks gestation arrives at the clinic asks the practical nurse if she is ready to have her baby soon. Which finding should the practical nurse (PN) respond to first? A. Continues to experience morning nausea and hiccups. B. Reports feeling wet and warm as if she is voiding involuntarily. C. Experiences abdominal contractions that occur every day. D. States that breathing is easier since the fundus height dropped. - B. Reports feeling wet and warm as if she is voiding involuntarily. Rationale: Rupture of the membranes that may leak at first and is often reported as a sensation of perineal wetness (B), so the PN should assess first the client for early sign of labor. (A, B, and D) are common findings in the last trimester that do not indicate the onset of true labor. The practical nurse (PN) is caring for four clients. Which client's data requires further nursing action? A. An adult with type 2 diabetes mellitus (DM) who has fasting glucose levels at 190 mg for 3 days. B. An older adult with head injury who has sequential hourly Glasgow Coma Scale (GCS) scores of 13, 14, and 15. C. An adolescent with pneumonia who has white blood cell count of 10,000/mm3 2 days after receiving antibiotics. D. An adult with a pulse of 110 and blood pressure of 150/80 following a lumbar puncture. - A. An adult with type 2 diabetes mellitus (DM) who has fasting glucose levels at 190 mg for 3 days. RATIONALE: The client with DM (A) who has fasting glucose levels of 190 mg for 3 days needs further action for the uncontrolled serum glucose. (B) is improving with a final GCS of 15, which is normal. (C) is improving since the white blood cell count is within normal. (D) may be related to anxiety after a lumbar puncture procedure, continued monitoring is indicated. A child who is currently undergoing chemotherapy (CT) for leukemia is brought to the clinic for a possible broken ankle. What priority action should the practical nurse implement? A. Obtain a current white blood cell (WBC) count. B. Place a mask on the child. C. Take the child's temperature and pulse. D. Apply ice and elevate the ankle. - B. Place a mask on the child. Rationale: The child who is receiving CT for leukemia is immunosuppressed and should be protected from airborne pathogens and other sick children in the clinic. Placing a mask on the child (B) provides transmission-based precautions that reduces the risk of the child to pathogens by droplet and takes priority over the WBC count (A), vital signs (C), or first aid treatment to the ankle (D). Which client should the practical nurse (PN) obtain a Glasgow Coma Scale (GCS) score? A. A female client with Alzheimer's disease. B. An adolescent male who hit his head due to alcohol toxicity. C. A male client who is chemically paralyzed and intubated. D. A young adult female with bipolar disorder. - B. An adolescent male who hit his head due to alcohol toxicity. Rationale: The GCS score evaluates a client's neurological responses after experiencing an acute head injury. Although alcohol toxicity may alter the adolescent's responses, the GCS score should be implemented during and after alcohol detoxification to screen for neurological changes characteristic of a head injury (B). (A, C, and D) do not experience changes in spontaneity of eye opening, best verbal response, and best motor response consistent with a head injury A client who was struck by a baseball on the right temple is admitted for 24-hour observation. What finding should the practical nurse (PN) report to the nurse immediately? A. Complains of feeling dizzy. B. Red blood oozing from a facial laceration. C. Heart rate 110 beats/minute; blood pressure 130/70. D. Right pupil size 9 mm; left pupil size 6 mm. - D. Right pupil size 9 mm; left pupil size 6 mm. Rationale: Anisocoria, or unequal pupil size (D), is a sign of intracranial compression after head injury and should be reported immediately for follow-up management. (A) is a common finding following a head injury. The face is highly vascular, so (B) is not unexpected. (C) can be slightly elevated due to pain and anxiety and are not in a critical finding The healthcare provider prescribes ketorolac (Toradol) 15 mg IM for a client in pain. The available concentration is 30 mg/ml. How many ml should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) - •0.5 Using ratio and proportion, 30 mg : 1 ml :: 15 mg : X 30X = 15 X = 0.5 ml A client who sustained a C4 injury in a head-on automobile collision is admitted to the neurological unit. Which priority assessment should the practical nurse (PN) monitor? A. Depth of respirations. B. Neuro focused checks. C. Pedal pulses. D. Blood pressure. - A. Depth of respirations. Rationale: The cervical plexus (first 4 cervical nerves) includes the phrenic nerve which innervates the diaphragm, so a C-4 cord injury can cause respiratory distress, which requires close monitoring of respiratory depth (A) to monitor the adequacy of oxygenation, the priority. Breathing is the priority over neurological checks (B), pedal pulses (C), and blood pressure (D).