HESI Foundations Final Exam

HESI Foundations Final Exam 1. The practical nurse (PN) is providing skin care to an older male client who has the tendency to stay on his left side in a lying position. Which bony prominence should the PN identify as the site most likely to develop alterations in skin integrity? A. Ilium. Correct 2. 2.ID: 09 The practical nurse (PN) is preparing to give a complete bed bath to an unconscious client. After implementing standard precautions before the procedure, what action should the PN implement next? A. Wash each eye with a fresh area of a washcloth before washing the rest of the face. Correct 3. 3.ID: 41 When providing perineal care for an uncircumcised male client, the practical nurse (PN) should implement which action? A. Retract the foreskin before cleansing the glans and replace the foreskin after the procedure. Correct 4. 4.ID: 93 The healthcare provider prescribes a vest restraint for an older male resident in a long-term facility who frequently falls out of his wheelchair. Which action should the practical nurse (PN) implement? A. Remove device every 2 hours and change client’s position. Correct 5. 5.ID: 15 The healthcare provider prescribes wrist restraints for a client who is agitated and combative. Which action should the practical nurse (PN) implement? A. Check the client's skin color, warmth, and pulses distal to the restraining device. Correct 6. 6.ID: 83 A client who is placed in wrist protective devices begins to complain of pain and swelling in one hand. The practical nurse (PN) notes that both hands are cool and pale. What action should the PN implement? A. Remove both devices and notify the healthcare provider. Correct 7. 7.ID: 17 The practical nurse (PN) notifies the healthcare provider that a male client has become combative and needs a protective device to prevent injury to self and others. Which principle should the PN use when selecting a protective device? A. A protective device provides the least amount of immobilization. Correct 8. 8.ID: 99 The practical nurse (PN) hears an auscultatory gap in the Korotkoff sounds of an older client with hypertension. What action should the practical nurse (PN) implement when obtaining the client's blood pressure? A. Continue to listen for the next Korotkoff sound until the cuff is deflated. Correct 9. 9.ID: 97 The practical nurse (PN) obtains an irregular pulse rate of 102 beats/minute for a client with a history of cardiac disease. Which action is most important for the PN to implement? A. Listen to the apical rate for one full minute. Correct 10. 10.ID: 31 For several days after her husband's death, a client who is admitted with acute depression repeats over and over, "I should have made him go to the doctor when he said he didn't feel well." Which descriptor should the practical nurse use to document the client's feelings?