HESI PN UPDATED SETS ANSWERS AND QUESTIONS
SET A+
✔✔When entering the room of an older female resident of a long term care facility, the
PN finds one of the male residents in bed with her. What action should the PN take? -
✔✔Close the door and report the finding to the charge nurse
✔✔Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120
beats/min. Based on this finding what action should the PN take? - ✔✔give the
medication and document the heart rate
✔✔A resident of a long-term care facility who has a drainage stage 2 pressure ulcer
receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to
the site. What precautions should the PN take when performing this procedure? select
all that apply - ✔✔-remove soiled dressings with procedure gloved and don sterile
gloves for moist dressing application
-place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the
dressed site
-pour warmed sterile solution to an open sterile dressing tray that contained sterile
gauze pads
✔✔A male client who is diagnosed with schizophrenia is taking an antipsychotic
medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff,
has a temperature of 103.4 F and is sweating. How should the PN respond to this
client? - ✔✔direct the client to obtain immediate transportation to the emergency center
✔✔The Glasgow coma scale is being used to monitor a client in the critical care unit.
The scale is used to evaluate what client status? - ✔✔level of conscious
✔✔A client is diagnosed with with hyperthyroidism. Which symptoms should the PN
expect this client to exhibit? - ✔✔muscle cramping and dry flushed skin
,✔✔The PN administers an antibiotic to a client with a respiratory tract
infection...evaluate the medications effectivesnn, which laboratory values should the PN
monitor? - ✔✔b,d ABD
✔✔To obtain an estimate of a clients systolic blood pressure, what action should the PN
take first? - ✔✔palpate the clients brachial pulse
✔✔A client reports feeling numbness and tingling in extremities. What action should the
PN implement? - ✔✔review the clients serum electrolyte levels
✔✔Immediately after birth, which nursing intervention has the highest priority for the
newborn infant? - ✔✔preventing heat loss and neonatal cold stress
✔✔The PN overhears a female client with Cushings syndrome tell her family in a...very
loud and angry voice to leave her room and not come back. The response by the PN is
baed on recognizing which common manifestation of the syndrome? - ✔✔mood
alterations
✔✔A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical
pulse rate is 54 beats/minute. What action should the PN take next? - ✔✔determine the
level of consciousness
✔✔After three weeks of antibiotic therapy, a child who weighs 55 pounds develops
painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg
daily. How many mg should the PN administer to this child? - ✔✔500
✔✔The PN is assisting a client to the bathroom after right cataract extraction. The client
has an eye shield over the right eye. How should the PN asset the client during
ambulation? - ✔✔stand in front of the client and lead the client forward to the bathroom
✔✔which client information is most important for the PN to consider when providing
instructions to the UAP about providing morning care to a postoperative client? -
✔✔urinary output of 50 mL/hour
✔✔A male client who was admitted with gangrene of the right lower extremity is
confused ad his wife refuses to sign the operative permit for an above the knee
amputation. What action should the PN take first? - ✔✔encourage the clients wife to
express concerns
✔✔After report, the PN receives the laboratory values for four clients. Which client
requires the PNs immediate intervention? - ✔✔a client who is trembling and has a
glucose level of 50
, ✔✔Based on the nursing diagnosis of "risk for infection" which intervention should the
PN implement when providing care for an elderly client with urinary incontinenece -
✔✔maintain standard precautions
✔✔During recovery after the delivery of a normal infant a client is receiving...ringers
1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic
response? - ✔✔stimulation of uterine contractions
✔✔The spouse of a hospitalized client asks the PN for acetaminophen for a tension
headache. Which action should the PN take? - ✔✔explain that medication can only be
provided to clients
✔✔A 5-year old child is admitted with full thickness burns over 30% of the total body
surface areas (TBSA). After fluid replacement therapy is initiated, which finding should
the PN use to evaluate the effectiveness of the therapy? - ✔✔urine output
✔✔when the PN attempts to assist an 18-year old female client with 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! Ill get up when I'm ready!" which
response is best for the PN to make? - ✔✔I know you feel very angry about the pain of
ambulation but this is a necessary part of getting well
✔✔A client with hypertension complains of a persistent dry cough. The PN should tell
the client that this is a common side effect of which daily medication? - ✔✔Quinapril
✔✔The PN enters the room of a client who is disoriented and has a wrist restraint
secured as seen in the picture what action should the PN take? photo is of hospital bed
and restraint Is on the bed frame in a bow tie - ✔✔use a full knot to secure the restraint
line
✔✔The PN views the mid-line episiotomy of a client who reports pain in her stitches.
What action should the PN take first? - ✔✔observe suture line for separation and
hematoma formation
✔✔A new mother asks the pn about an area of swelling on her baby head that lies
across the suture line near the posterior fontanel. How should the PN respond? -
✔✔caput succedaneum will be absorbed and causes no problem
✔✔The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is
conscious and demonstrating hand tremors and shaking. The PN reports the clients
result of 55 mg/dL to the nurse. What action should the PN implement next? -
✔✔provide the client with a glass of milk and crackers
SET A+
✔✔When entering the room of an older female resident of a long term care facility, the
PN finds one of the male residents in bed with her. What action should the PN take? -
✔✔Close the door and report the finding to the charge nurse
✔✔Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120
beats/min. Based on this finding what action should the PN take? - ✔✔give the
medication and document the heart rate
✔✔A resident of a long-term care facility who has a drainage stage 2 pressure ulcer
receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to
the site. What precautions should the PN take when performing this procedure? select
all that apply - ✔✔-remove soiled dressings with procedure gloved and don sterile
gloves for moist dressing application
-place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the
dressed site
-pour warmed sterile solution to an open sterile dressing tray that contained sterile
gauze pads
✔✔A male client who is diagnosed with schizophrenia is taking an antipsychotic
medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff,
has a temperature of 103.4 F and is sweating. How should the PN respond to this
client? - ✔✔direct the client to obtain immediate transportation to the emergency center
✔✔The Glasgow coma scale is being used to monitor a client in the critical care unit.
The scale is used to evaluate what client status? - ✔✔level of conscious
✔✔A client is diagnosed with with hyperthyroidism. Which symptoms should the PN
expect this client to exhibit? - ✔✔muscle cramping and dry flushed skin
,✔✔The PN administers an antibiotic to a client with a respiratory tract
infection...evaluate the medications effectivesnn, which laboratory values should the PN
monitor? - ✔✔b,d ABD
✔✔To obtain an estimate of a clients systolic blood pressure, what action should the PN
take first? - ✔✔palpate the clients brachial pulse
✔✔A client reports feeling numbness and tingling in extremities. What action should the
PN implement? - ✔✔review the clients serum electrolyte levels
✔✔Immediately after birth, which nursing intervention has the highest priority for the
newborn infant? - ✔✔preventing heat loss and neonatal cold stress
✔✔The PN overhears a female client with Cushings syndrome tell her family in a...very
loud and angry voice to leave her room and not come back. The response by the PN is
baed on recognizing which common manifestation of the syndrome? - ✔✔mood
alterations
✔✔A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical
pulse rate is 54 beats/minute. What action should the PN take next? - ✔✔determine the
level of consciousness
✔✔After three weeks of antibiotic therapy, a child who weighs 55 pounds develops
painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg
daily. How many mg should the PN administer to this child? - ✔✔500
✔✔The PN is assisting a client to the bathroom after right cataract extraction. The client
has an eye shield over the right eye. How should the PN asset the client during
ambulation? - ✔✔stand in front of the client and lead the client forward to the bathroom
✔✔which client information is most important for the PN to consider when providing
instructions to the UAP about providing morning care to a postoperative client? -
✔✔urinary output of 50 mL/hour
✔✔A male client who was admitted with gangrene of the right lower extremity is
confused ad his wife refuses to sign the operative permit for an above the knee
amputation. What action should the PN take first? - ✔✔encourage the clients wife to
express concerns
✔✔After report, the PN receives the laboratory values for four clients. Which client
requires the PNs immediate intervention? - ✔✔a client who is trembling and has a
glucose level of 50
, ✔✔Based on the nursing diagnosis of "risk for infection" which intervention should the
PN implement when providing care for an elderly client with urinary incontinenece -
✔✔maintain standard precautions
✔✔During recovery after the delivery of a normal infant a client is receiving...ringers
1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic
response? - ✔✔stimulation of uterine contractions
✔✔The spouse of a hospitalized client asks the PN for acetaminophen for a tension
headache. Which action should the PN take? - ✔✔explain that medication can only be
provided to clients
✔✔A 5-year old child is admitted with full thickness burns over 30% of the total body
surface areas (TBSA). After fluid replacement therapy is initiated, which finding should
the PN use to evaluate the effectiveness of the therapy? - ✔✔urine output
✔✔when the PN attempts to assist an 18-year old female client with 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! Ill get up when I'm ready!" which
response is best for the PN to make? - ✔✔I know you feel very angry about the pain of
ambulation but this is a necessary part of getting well
✔✔A client with hypertension complains of a persistent dry cough. The PN should tell
the client that this is a common side effect of which daily medication? - ✔✔Quinapril
✔✔The PN enters the room of a client who is disoriented and has a wrist restraint
secured as seen in the picture what action should the PN take? photo is of hospital bed
and restraint Is on the bed frame in a bow tie - ✔✔use a full knot to secure the restraint
line
✔✔The PN views the mid-line episiotomy of a client who reports pain in her stitches.
What action should the PN take first? - ✔✔observe suture line for separation and
hematoma formation
✔✔A new mother asks the pn about an area of swelling on her baby head that lies
across the suture line near the posterior fontanel. How should the PN respond? -
✔✔caput succedaneum will be absorbed and causes no problem
✔✔The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is
conscious and demonstrating hand tremors and shaking. The PN reports the clients
result of 55 mg/dL to the nurse. What action should the PN implement next? -
✔✔provide the client with a glass of milk and crackers
