HESI PN Practice Test 264 Questions with Verified Answers,100% CORRECT

HESI PN Practice Test 264 Questions with Verified Answers A male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? - CORRECT ANSWER Determine the amount of water and exact time it was taken A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this medication? - CORRECT ANSWER Monitor the client for nausea or vomiting following the treatment During morning rounds a client is admitted with OCD is in the...of the same table. What intervention should the PN implement when approached? - CORRECT ANSWER Provide time for the behavior then guide the client to other activities The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? - CORRECT ANSWER Has increasing episodes of urinary incontinence The pn determines that a client with cirrhosis is experiencing peripheral....take? - CORRECT ANSWER Protect the clients feet from injury A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement? - CORRECT ANSWER Maintain system integrity and to promote lung reexpansion photo of chest and locating apical HR - CORRECT ANSWER just below the left nipple At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN take next? - CORRECT ANSWER note the most recent white blood count A client with a compound fracture of the left ankle is being discharged with a below the knee cast....PN provide to the client prior to discharge? - CORRECT ANSWER never scratch under the cast Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? - CORRECT ANSWER implement complementary pain relief methods A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. the morning the PN observes that he...Which intervention is most important for the PN to implement? - CORRECT ANSWER Measure appropriate vital signs The PN is assisting an unsteady client to ambulate from the bed to the bath...client loses balance and falls onto the bedside table. what action should the PN take first? - CORRECT ANSWER Stay with the client and call for assistance The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next? - CORRECT ANSWER initiate the urine stream? An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN? - CORRECT ANSWER weights are touching the foot of the bed The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take? - CORRECT ANSWER Encourage the client to continue the dietary changes she has made A 3-year old child returns to the pediatricians office for a postoperative visit after having...procedure. The PN should expect to observe which behavior that indicates... - CORRECT ANSWER plays doctor and nurse with the dolls The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... - CORRECT ANSWER -why the fluid measurements need to be recoded -which food types are included when measuring fluid take -what container to use for the most accurate measurement A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice daily in equal dosages.How many tablets should the PN... - CORRECT ANSWER 3 ... - CORRECT ANSWER request return visit for examination after her period when hormones are lowest A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? - CORRECT ANSWER -The 6-year old son hits his younger sister during the interview -the 10-year old daughter has circular burns on her trunk and legs -the 3-year old has multiple bruises on the chest and both legs A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy? - CORRECT ANSWER 1700 the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? - CORRECT ANSWER gastric residual volumes A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? - CORRECT ANSWER Ensure that all the areolar tissue of the nipple is in the infants mouth. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? - CORRECT ANSWER deltoid Before inserting medication into a clients vagina, what instructions should the pn... - CORRECT ANSWER urinate until bladder is empty An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? - CORRECT ANSWER A history of untreated gonnorhea can lead to PID A 28-year old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement? - CORRECT ANSWER extend the leg and flex the foot? A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? - CORRECT ANSWER Wear a supportive bra at all times A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include in the assessment of this client? - CORRECT ANSWER "what are the voices uttering?" A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? - CORRECT ANSWER Self-actualiztion A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? - CORRECT ANSWER Explain risks associated with using herbs instead of the prescribed antihypertensives. A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? - CORRECT ANSWER Act as the clients advocate when discussing the issue with the HCP The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? - CORRECT ANSWER watch the client for abnormal bleeding ... - CORRECT ANSWER "it is better to obtain children acetaminophen to prevent possible side effects from the aspirin " A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? - CORRECT ANSWER neuro-vital signs related to bleeding and intracranial pressure The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of.. - CORRECT ANSWER total the clients PO intake, fill the water pitchers, empty urinals and catheter bags. While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information.... - CORRECT ANSWER screening for tardive dyskinesia A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? - CORRECT ANSWER position client in left lateral position to inspect perianal area for fissures or sacs the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? - CORRECT ANSWER Begins to show signs of improvement ... - CORRECT ANSWER -Assess the condition of the IV site -loosen tape that secures the existing tubing -remove existing tubing and spike new tubing into bag -clamp the IV catheter and attach the new tubing -unclamp the tubing and IV catheter and begin the infusion The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? - CORRECT ANSWER observe the appearance of the urine in the drainage tubing A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report... - CORRECT ANSWER urinary output of 20 mL/hr The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement? - CORRECT ANSWER report the findings to the charge nurse The PN is making shift assignment at an extended care rehabilitation...assign to the UAP. - CORRECT ANSWER -Toileting assistance for a client receiving therapy after a total hip replacement -daily skin care for a client with a descending double barrel colostomy -morning care for a client with a staph wound infection A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? - CORRECT ANSWER Obtain prescribed calcium gluconate for tetany A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? - CORRECT ANSWER History of alcohol and tobacco use An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate... - CORRECT ANSWER Consecutive evening serum glucose readings of 260 mg/dl The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments - CORRECT ANSWER -A client who is admitted with a suspected ruptured appendix -A client who is post-lumbar puncture is reporting a severe headache -An older male adult with Alzheimers who wanders out of his room -A postoperative client who needs reinforcement of discharge instruction ...the partner refuses to go. The PN suspects the injuries may be the result of... - CORRECT ANSWER Arrange to take the client to the operating room holding area for privacy The PN is caring for a client whose urine drug screen is positive for...exhibit during cocaine withdraw - CORRECT ANSWER powerful craving for more The PN is with a client when the health care provider explains that the..tumor.Later in the morning the client asks the PN "What do the letters T,N,M: star for? - CORRECT ANSWER The letters stand for tumor size, node involvement, and metastasis Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? - CORRECT ANSWER Review with the client the need to avoid foods that are rich in milk and cream An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete? - CORRECT ANSWER Ask about occurrence and frequency of nosebleeds The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care? - CORRECT ANSWER interventions to decrease emotional stress An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ? - CORRECT ANSWER reinforce the need for extra rest periods and plenty of sleep The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? - CORRECT ANSWER Affirm the importance of rest to promote liver healing when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication?` - CORRECT ANSWER An older client with a stroke who is febrile and confused which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? - CORRECT ANSWER Report any food injury or sore that does not readily heal during a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0bmL q/L. Which action should the PN recommend to the client based on this finding? - CORRECT ANSWER increase intake of dried peaches and apricots A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? - CORRECT ANSWER The left foot is warm to touch with a palpable dorsals pedis pulse 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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 - CORRECT ANSWER -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? - CORRECT ANSWER 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? - CORRECT ANSWER level of conscious A client is diagnosed with with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? - CORRECT ANSWER 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? - CORRECT ANSWER b,d ABD To obtain an estimate of a clients systolic blood pressure, what action should the PN take first? - CORRECT ANSWER palpate the clients brachial pulse A client reports feeling numbness and tingling in extremities. What action should the PN implement? - CORRECT ANSWER review the clients serum electrolyte levels Immediately after birth, which nursing intervention has the highest priority for the newborn infant? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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 - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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 - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER provide the client with a glass of milk and crackers A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? - CORRECT ANSWER send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour the PN plans to evaluate an adults response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? - CORRECT ANSWER pain scale level during walking The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the clients urine is the color of dark tea. What action should the PN take? - CORRECT ANSWER encourage increased oral fluid intake In administering nystantin suspension to the gums of an infant with a candida infection, which approach should the PN take? - CORRECT ANSWER use a gloved finger to rub the suspension over the infected area While the PN and UAP are turning a client with an abdominal incision, the clients incision eviscerate. Which task is best for the PN to assign to the UAP? - CORRECT ANSWER gather supplies A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? - CORRECT ANSWER plasma protein losses resulting in decreased oncotic pressure within the vessels The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? - CORRECT ANSWER demonstrate to the UAP how to approach the client from the clients left side An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dL . She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse? - CORRECT ANSWER aspirin The PN is planning care for a client who has generalized tonic clonic seizures and is vomiting and having frequent diarrhea stools. to reduce the risk of injury to this client which nursing measurements should the PN implement? - CORRECT ANSWER axillary temperatures and padded side rails when assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. he also has a history of gastroesophogeal reflux disease and depression. which interventions is most important for the PN to implement? - CORRECT ANSWER review the clients use of over the counter (OTC) medications A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? - CORRECT ANSWER confirm that the desired effect of the medication has been achieved? A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal ? - CORRECT ANSWER emphasize the importance of active foot flexion After applying alcohol based hand rub to the palms of the hand and rubbing paps together what action should the PN take next? - CORRECT ANSWER place hands on top of each other and interlace fingers A new mother is bottle feeding instead of breastfeeding the PN should instruct the to most effective way to deal with breast engorgement and discomfort is to? - CORRECT ANSWER wear a supportive bra at all times Because of staffing shortages the charge nurse assigns a PN to perform a skill which the PN is not yet certified to perform what is the best response by the PN? - CORRECT ANSWER I am uncomfortable performing a skill which I am not certified A client recovering from a stroke is learning how to use a cane. How should it be placed? - CORRECT ANSWER on the stronger side of the body A client with schizophrenia is withdrawn isolates himself in the day room and answers questions with one or two word responses which intervention is most important ? - CORRECT ANSWER measure appropriate vital signs While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? - CORRECT ANSWER expected finding A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? - CORRECT ANSWER give 4 ounces of apple juice A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks. What should the nurse tell the mom? - CORRECT ANSWER ensure that all the areola tissue of the nipple is in the infants mouth A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? - CORRECT ANSWER provide oral care The PN is caring for a client in bucks tract what is the priority goal for the client in traction? - CORRECT ANSWER maintain straight body alignment Which site should the PN use when administering RHO D - CORRECT ANSWER deltoid Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? - CORRECT ANSWER offer emotional support to the family when should a person use additional birth control precautions? - CORRECT ANSWER when taking antibiotics for an infection Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the PN nurse observe when administering direct client care? - CORRECT ANSWER minimal time maximum distance and protective shielding Client voiding small amounts every 24 hours - CORRECT ANSWER the catherterized volume determines the need to reinsert the indwelling catheter Based on the principle of asepsis the PN should consider which situation to be sterile? - CORRECT ANSWER An open Foley catheter kit set up on a table at the PN waist level A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client? - CORRECT ANSWER measure all emeisies accurately Single mother of a child with head injury comes crying to the clinic what should the PN tell her? - CORRECT ANSWER this must seem overwhelming to you right now on admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? - CORRECT ANSWER erythema and indurations of 5mm at site When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take? - CORRECT ANSWER contact the medication nurse to clarify the findings The hearing of ringing in the ears what medication should be reported to the Health provider ? - CORRECT ANSWER Gentamicin 28 year old client is in active labor and complains of a cramp in her leg. what intervention should the PN implement ? - CORRECT ANSWER extend the leg and flex the foot A client is admitted for observation after experiencing a TIA - CORRECT ANSWER high risk for injury Which picture of nailbeds indicate hypoxia? - CORRECT ANSWER choose the one that has a bump right below the nail bed The nurse assesses a child in 90-90 traction. Where should the nurse assess for signs of compartment syndrome? the picture will show a child in traction with left left in traction - CORRECT ANSWER click on the toes of the elevated leg During morning report the PN learns that an assigned client has phlebitis from a intravenous access device. What will the PN observe in this client? - CORRECT ANSWER redness, warmth, and edema of the site A client is prescribed lorazepam (Ativan) 0.5 mg oral suspension every 6 hours as needed for anxiety. The medication is available as 2 mg/mL oral suspension. How many mL of the medication will the PN provide for each dose? - CORRECT ANSWER 0.3 mL Why would the PN schedule physical therapy in the morning for a client with myasthenia gravis? - CORRECT ANSWER The muscles are strongest in the morning The PN is caring for a client with atrial fibrillation. What would be an expected finding when assessing this client? - CORRECT ANSWER heart rate 88 and irregular A clients blood pressure is unusually elevated. Which factors would contribute to this clients blood pressure elevation? - CORRECT ANSWER stress exercise heart rate body temp During morning report the PN learns that an assigned client has phlebitis from an intravenous access device. What manifestations will the PN assess in this client? - CORRECT ANSWER palpable cord along the vein While measuring an orthostatic blood pressure the client becomes dizzy. What would the PN do? - CORRECT ANSWER assist the client to site down Why does the PN wear a pair of clean gloves when providing care to a client with clostridium difficile ? - CORRECT ANSWER to protect the nurse from microorganisms that is within the client A client with lower back pain has been prescribed a transcutaneous electrical nerve stimulator (TENS) unit for pain control. Why would the client be instructed to use this device on the low frequency setting? - CORRECT ANSWER stimulate serotonin levels The PN is reviewing actions for a mother to take to prevent her toddler from being injured in the home. What will the PN emphasize with this mother? - CORRECT ANSWER keep poisonous and other materials locked away How should the PN assist the client to provide sputum sample? - CORRECT ANSWER coach the client to take deep breaths and cough deeply to mobilize secretions A client with a fever is diaphoretic and the linens are saturated. After assessing the clients vital signs, which action would the PN take? - CORRECT ANSWER change the bed linens The mother of a toddler demonstrating a sudden onset of stridor says that the child was playing with an old shirt and suddenly could not breathe very well. What would the PN suspect has occurred with this client? - CORRECT ANSWER the child aspirated a button from the shirt The PN has identified the howling statement as a desired outcome for a client "client will report effective pain management when using analgesic medication every 6 hours as prescribed." This outcome statement would be appropriate for which client problem? - CORRECT ANSWER ineffective pain management A client recovering from surgery to the fibula has bleeding on the cast. The PN outlines the border of bleeding to serve at a baseline. Which action would the PN do next? - CORRECT ANSWER recheck the cast within the next 15 minutes A client who received 10 units of regular insulin is diaphoretic and is shaky. Why would the PN provide the client with graham crackers and milk? - CORRECT ANSWER the client is experiencing hypoglycemia A client with multiple sclerosis has developed a bladder infection. What would the PN identify as a possible cause for this infection? - CORRECT ANSWER immunosuppressant therapy Why does the PN administer ophthalmic ointment in the eyes of a newborn? - CORRECT ANSWER to prevent gonorrheal or chlamydial ophthalmic infections A 40 year old client has obtained a baseline mammogram. When would the PN recommend that the next mammogram be performed? - CORRECT ANSWER in 1 year The PN assesses a moon-shaped face and muscle wasting in a client receiving dexamethasone (Decadron). What will these manifestations suggest to the PN? - CORRECT ANSWER Cushings syndrome A client prescribed to receive terbutaline sulfate (Brethren) 0.25 mg subcutaneous injection three times a dat at 6 hour intervals. The medication is available as 1 mg/mL. How many mL of the medication will the PN provide to the client for one day? - CORRECT ANSWER 0.75 The PN provides a prescribed analgesic perianal spray to a postpartum client. For which problem will this nursing action address? - CORRECT ANSWER vaginal lacerations the PN is reviewing new orders for a client and notes that medication doses have been adjusted to lower levels than what is routinely prescribed. Why would this action be taken for the client? - CORRECT ANSWER the client has renal failure The PN is positioning a client recovering from a radical mastectomy. Why will the PN place the client in the semi-fowlers position with the arm of the operative side elevated? - CORRECT ANSWER to prevent edema in the arm The charge nurse is making assignments for client care. Which client would be assigned to the PN for the assessment? - CORRECT ANSWER client with confusion and sundowner syndrome While administering morning care to a client, the UAP informs the PN that the clients lower extremity wounds are leaking bloody drainage. What action would the PN take? - CORRECT ANSWER direct the UAP to accumulate wound dressing supplies A client with a chest tube attached to a water sealed drainage system has had 400 mL of drainage over the last 8 hours. After morning care the client was repositioned and the chest tube drainage has been 0 ml for the last 2 hours. What action would the PN take at this time? - CORRECT ANSWER increase the suction on the drainage system The PN is caring for a client recovering from a transurethral resection of the bladder for prostate hypertrophy. The client has an indwelling urinary catheter and is receiving continuous bladder irigation of sterile normal saline at 100 mL per hour. the health care provider has prescribed to reduce the irrigation to 50 ml/hr if the clients output measurement is equal to 550 mL for 4 hours at which point would the PN reduce the clients bladder irrigation - CORRECT ANSWER 1000 output measurement 550 mL The PN contacts a clients health care provider to report that a client is refusing medication and other treatments prescribed for a health problem. Which moral principle is the PN supporting at this time? - CORRECT ANSWER clients right to autonomy What equipment will the PN ensure is present before delegating the task of feeding a client on aspiration precautions to UAP? - CORRECT ANSWER Suction A client is at a high risk for injury. Which action would the PN take to ensure for the clients safety? - CORRECT ANSWER raise the side rails and provide the client with the call light for assistance The PN is caring for a client with an enlarged liver. When assessing this client on which part of the abdomen will the nurse focus? - CORRECT ANSWER right upper quadrant While inserting an indwelling urinary catheter into a female client the catheter slips into the clients vagina. What would the PN do? - CORRECT ANSWER keep the catheter in the vagina and insert a new catheter through the urethral meatus A client is having a lumber puncture. in which position would the PN assist the client into assuming? - CORRECT ANSWER fetal position Why would the PN wash the skin of a client receiving external radiation with water? - CORRECT ANSWER to prevent skin irritation and damage the PN is planning to assess a clients kidneys. What is the orientation of these organs within the abdominal cavity? - CORRECT ANSWER retroperitoneal to the perineum A client is admitted to a private room tells the PN that the insurance carrier will not pay for the private accommodations. What would the PN resound to the client ? - CORRECT ANSWER the insurance carrier will cover the cost of the room if there are no semi private rooms available Six hours after removing a clients indwelling urinary catheter the client has not voided ad is expressing discomfort from a distended bladder. What action would the PN take? - CORRECT ANSWER obtain an order for intermittent urinary catheterization The PN is assessing a clients home environment for safety Which action would the PN suggest to reduce the risk of falls in the home? - CORRECT ANSWER instruct to keep all walkways and steps clear of clutter A client is prescribed losartan (Cozaar) for high blood pressure What will the PN remind the client do to prevent sudden dizziness? - CORRECT ANSWER move slowly when changing positions During a health history the PN learns that an older client had the chickenpox virus as a child. Which immunization would be indicated for the client at this time? - CORRECT ANSWER vaccination for shingles A client is prescribed cefazolin sodium (Ancef) 300 mg intramuscular injection every 8 hours. The PN has a 500 mg vial of medication that will be reconstituted with 2 mL of sterile water for injection. After reconstitution the volume of medication will be 2.5 ml. How many ml of medication will the PN provide in one dose for the client? - CORRECT ANSWER 1.5 The PN is reviewing the state nurse practice act. What information will be included within the document? - CORRECT ANSWER legal requirements for PN A client being treated with prednisone (Deltasone) for a skin infection tells the PN that the medication was stopped a few days prior because the rash disappeared. What action would the PN take at this time? - CORRECT ANSWER notify the HCP that the client did not complete the medication The PN is caring for a client with pneumonia. Why will the nurse ambulate with the client every 2 hours while awake? - CORRECT ANSWER mobilize secretions When applying an eye shield to a clients left eye, why does the PN tape the shield from the mid-forehead to the left zygomatic process? - CORRECT ANSWER secure the shield with the least amount of facial movement? The PN observes a family member provide passive ROM to a client paralyzed upper extremity, The family member is supporting the client elbow by holding above and below the joint through ROM. Which action would the ON take after making this observation? - CORRECT ANSWER encourage the family member to continue because the procedure is being done correctly When the PN strokes the right side of a newborns cheek the baby turns the head towards the side that is stroked and opens opens the lips. Which reflex is the PN assessing? - CORRECT ANSWER rooting A client who received in vitro fertilization has an examination to learn that the procedure was unsuccessful. The client is sitting quietly in the examination room and begins to cry. Which action would the PN take at this time? - CORRECT ANSWER Sit with the client A newborn has just been fed and the PN is preparing to change the baby diaper. Why would the PN ensure that a bulb syringe is available at this time? - CORRECT ANSWER to aspirate formula in the event the baby vomite when lying flat A client is admitted for treatment of diabetic ketoacidosis. Which manifestation will the PN assess in this client? - CORRECT ANSWER fruity breath odor Why would the PN encourage the client to use incentive spirometer after surgery? - CORRECT ANSWER to prevent onset of repository complications an older client with a new onset of confusion tells the family that the nursing staff is "holding her hostage" the family is upset and wants to know what is happening with the client. What would the PN respond to this inquiry? - CORRECT ANSWER the client is experiencing confusion The PN assesses an improvement in a clients mood after taking a prescribed antidepressant medication for a week. What does this finding suggest to the nurse? - CORRECT ANSWER the medication is effective a client is diagnosed with respiratory acidosis. What blood pH value will the PN assess when reviewing the clients arterial blood gas results? - CORRECT ANSWER 7.29 The PN observes a client with major depression giving personal items away to staff and other clients. What does this observation indicate to the PN? - CORRECT ANSWER the client is planning to die A 16 year old client is preceded to receive 1.0 mL of an intramuscular injection. Which sites would the PN consider to administer this medication? - CORRECT ANSWER deltoid ventrogluteal A client who is preceded bed rest asks why PROM exercises are being done three times a day. What explanation would the PN provide to this client? - CORRECT ANSWER the will ensure that your joints are limber when you begin walking the PN provides cold packs to the perineum of a postpartum client with perineal hematoma. What will the PN do to evaluate the effectiveness of this action? - CORRECT ANSWER observe the hematoma for changes in size A client has sustained a burn affecting the clients adipose tissue and blood vessels. Which layer of the clients skin has been affected by the burn? - CORRECT ANSWER subcutaneous layer During the assessment go a school age child the PN determines that the client is in Ericksons developmental stage of industry vs inferiority. Which behavior did the client demonstrate? - CORRECT ANSWER sitting quietly reading a book while assessing a school age child about a new arm fracture the PN learns that the clients explanation for the injury is different from the one provided by the mother. What does this information suggest to the PN? - CORRECT ANSWER T he client is a victim of possible child abuse The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? - CORRECT ANSWER washing the hair of a client with a head injury The practical nurse is caring for a postpartum client. Based upon the information provided, which action would the nurse take? TAB 1 - Health Care Provider's - CORRECT ANSWER iti g Flow Sheet Date Hr 1 Hr 2 Hr 3 Pad count 2 3 2 Urine output 45 mL 35 mL 40 mL TAB 3 - Laboratory Results Date Laboratory Test Results Bilirubin level newborn 14 mg/dL Indirect Coombs' test mother Negative Direct Coombs' test newborn Positive - CORRECT ANSWER Administer Rh immune globulin The practical nurse sits at a slight angle to a client who is out of bed in a chair. What will this seating posture promote with the client? - CORRECT ANSWER verbalization When preparing to apply a new ostomy bag for a client's colostomy, why will the practical nurse measures the stoma size? - CORRECT ANSWER Ensure the bag fights tightly near the stoma A client with type 1 diabetes mellitus has a morning fasting blood glucose level of 70 mg/dL. Which action would the practical nurse take? - CORRECT ANSWER nothing since this is considered a normal blood glucose level A client with a bee sting has a respiratory rate of 28 and an oxygen saturation level of 80% on room air. What action would the practical nurse take at this time? - CORRECT ANSWER notify the HCP and prepare to administer O2 Why would the practical nurse remind a postpartum client receiving the rubella vaccine to avoid becoming pregnant for at least 3 months? - CORRECT ANSWER to ensure that any fetus is not affected by the live rubella virus When walking with an older client the practical nurse supports the client's upper torso. Why is the upper torso the center of gravity in an older client? - CORRECT ANSWER The hips and knees flex causing a stooped posture The practical nurse demonstrates to a client how to inhale through the nose with the mouth closed and exhale through pursed lips. What is the practical nurse reviewing with the client? - CORRECT ANSWER pursed lip. breathing The practical nurse needs to provide acetaminophen (Tylenol) to a sleeping client with a gastrostomy tube. The medication is prescribed as tablets, elixir, and suppository. How would the practical nurse provide the medication to the client? - CORRECT ANSWER via gastrostomy tube with the elixir A school-aged child is given a varicella zoster immune globulin injection. The practical nurse realizes this client has which chronic illness? - CORRECT ANSWER AIDS Which client care activity would a practical nurse delegate to unlicensed assistive personnel? - CORRECT ANSWER passive ROM exercises to a client with a stroke .A client recovering from a myocardial infarction is demonstrating pinktinged frothy sputum. What does this manifestation suggest to the practical nurse? - CORRECT ANSWER pulmonary edema The practical nurse positions a client with face and neck burns supine with the neck extended and resting on a rolled towel. Why is this position beneficial to the client? - CORRECT ANSWER it maximizes neck and face function An obese client asks why a high-protein diet will not help reduce her elevated cholesterol level. What would the practical nurse respond to this client? - CORRECT ANSWER A high protein diet consist of meat, poultry, and dairy products which are all high in cholesterol A 24-year-old client is experiencing amenorrhea. For which health condition will the practical nurse focus when assessing this client? - CORRECT ANSWER pregnancy After using an intermittent urinary catheter to drain the bladder of a postpartum client the practical nurse determines that the client's fundus is boggy. What action would the practical nurse take at this time? - CORRECT ANSWER massage the fundus A client with an external urinary catheter is complaining of pain. What would the practical nurse do to help this client? - CORRECT ANSWER remove the external device The lips and mucous membranes of an African-American client are dusty in color. What does this assessment finding suggest to the practical nurse? - CORRECT ANSWER low oxygen level The practical nurse writes the care plan of a client with partial-thickness burns "perform hand hygiene before and after providing care." What is the purpose of this action? - CORRECT ANSWER prevent infection A client recovering from a breast biopsy is told that the lesion is classified as being T1N1M0. What will the practical nurse explain this classification as being to the client? - CORRECT ANSWER There is one lymph node involved A client with end stage renal failure is refusing hospice care because of "not being ready to die." What can the practical nurse respond to the client at this time? - CORRECT ANSWER Why would the practical nurse count a client's apical heart rate for a full minute? - CORRECT ANSWER the clients heart rate is irregular A client with terminal cancer of the liver wants to leave the hospital and spend time at home before dying. Which action would the practical nurse take to help this client? - CORRECT ANSWER talk withe the HCP regarding hospice care for the client The practical nurse is caring for a client with an allergy to shellfish. Which diagnostic test would be impacted by this client's allergy? - CORRECT ANSWER intravenous pylegram A female client from a non-English speaking culture tells the male practical nurse that she will not perm it him to bathe her. The client has bowel incontinence and has been diaphoretic from a fever. Which action would the male practical nurse take? - CORRECT ANSWER ask a female PN to provide the client with a bath A client is prescribed a treatment in which the process of filtration will be used. How will the practical nurse explain this cellular transport mechanism to the client? p - CORRECT ANSWER mechanical pressure forces water and solutes through the membrane When ambulating a client who has been on bed rest why would the practical nurse first assist the client to a sitting position on the side of the bed? - CORRECT ANSWER to help determine the clients response to postural changes A client has an infiltrated intravenous access device in the right arm. To evaluate blood flow to this extremity, which arteries will the practical nurse assess? (Select all that apply.) - CORRECT ANSWER Brachial radial ulnar The charge nurse is making client care assignments on a busy medicalsurgical care area. Which client would be appropriate to assign to the practical nurse? - CORRECT ANSWER client recovering from a stroke needing subcutaneous heparin and gastrostomy feedings Prior to administering a prescribed tube feeding to a client with a gastrostomy tube why would the practical nurse aspirate for gastric residual volume? - CORRECT ANSWER the evaluate the amount of gastric emptying A client is scheduled for an electroencephalogram (EEG). What will the practical nurse instruct the client about this diagnostic test A? - CORRECT ANSWER you will have electrodes placed on your scalp on your scalp during the test The practical nurse is documenting the health history of a client who smokes one pack of cigarettes per day. Which client manifestation may be directly related to this lifestyle action? - CORRECT ANSWER chest pain that radiates down the left arm The practical nurse provides an older client with a prescribed narcotic pain medication. Why would the practical nurse encourage the client to drink more fluids while taking this medication? - CORRECT ANSWER decrease the onset of constipation When preparing to measure a client's blood pressure the practical nurse places the client's arm at the level of the heart. What is the importance of this action? - CORRECT ANSWER it ensures the most accurate reading The nurse is caring for a young adult client who uses intravenous drugs and has unprotected sexual intercourse with several partners. Which health promotion action would the practical nurse recommend for this client? - CORRECT ANSWER periodic HIV testing Which action would the practical nurse take to evaluate the hydration status of an infant recovering from abdominal surgery? - CORRECT ANSWER weigh diapers and assess urine specific gravity A client has refused to bathe for several days and tells the practical nurse it is because unlicensed assistive personnel are "rough" during the bath. What would the practical nurse do? - CORRECT ANSWER delegate the task to other UAP A client is prescribed dexamethasone (Decadron) 8 mg by mouth with breakfast. The medication is n - CORRECT ANSWER contact the pharmacy and ask that the medication be delivered now A client is prescribed erythromycin (E-mycin) 400 mg oral suspension every 4 hours. The medication available is 100 mg/5 mL. How many mL will the practical nurse administer to the client for each dose - CORRECT ANSWER 20 mL A client's respiratory rate is assessed as being 8 per minute. Which medication would the practical nurse suspect as causing this client's reduced respirations? - CORRECT ANSWER morphine sulfate A client has had a procedure that will result in scarring of the cervix. How will the effects of the procedure impact the client's ability to achieve pregnancy in the future? - CORRECT ANSWER Restrict the fertilization of the ovum The practical nurse is reviewing laboratory values for assigned clients. Which value would the practical nurse report immediately to the health care provider? ESTRICT - CORRECT ANSWER Hemoglobin level 7.0 mg/dL a picture of someone opening an ampule. - CORRECT ANSWER the person should be using an alcohol pad or a pad to break open the ampule so when you break the ampule glass doesn't break the ampule photo of a blood pressure cuff on a clients arm. What would you tell the person - CORRECT ANSWER palpate the brachial pulse which is on the inside of the arm common side effects of iron and are normal if the client report - CORRECT ANSWER black stool know which foods are high in b12 - CORRECT ANSWER the PN is preparing to remove an indwelling urinary catheter in a female client. Which action would the PN perform first? - CORRECT ANSWER deflate the balloon on the catheter Why would the PN provide a bronchodilator to a client with asthma prior to conducting postural drainage? - CORRECT ANSWER to mobilize secretions The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement? - CORRECT ANSWER select the one with hand covering both eyes There will be pictures of ECG - CORRECT ANSWER select the one that looks like a bunch of M's Which group of population the nurse assesses for scoliosis - CORRECT ANSWER young girls A nurse is talking loudly in the hall and everybody can hear her personal - CORRECT ANSWER suggest nurse go talk in the nurse lounge nurse assigns duty to UAP and the UAP just looks at the nurse and walks away what will the nurse do? - CORRECT ANSWER submit an incident report relating to the UAP behavior When administering iron medicine - CORRECT ANSWER take with grapefruit juice baby of diabetic mother was born jittery and blood glucose is 40 mg/dL what should the nurse implement? - CORRECT ANSWER breastfeeding or milk feeding the baby Patient has carotid endarterectomy how to observe for signs of bleeding? - CORRECT ANSWER check area around the neck and elbow pregnant lady reports greenish discharge from vagina nurse should advise the to test for - CORRECT ANSWER Gonorrhea When repositioning patient the nurse observes wound with a foul odor the nurse should... - CORRECT ANSWER check the white blood cell count fire starts what to do? - CORRECT ANSWER Remove patient activate the ALARM close door extinguisher this will be a prioritizing question of which patient to see first - CORRECT ANSWER the patient with bright red drainage coming out of anus after colonoscopy and polyp new mother says she thinks her baby head looks funny - CORRECT ANSWER instruct the mother that this is normal and round head shape will come back after 7-14 days patient with OCD states that he doesn't know what to do because people are laughing at him while they don't understand him and he cannot take this anymore - CORRECT ANSWER inquire for idea of suicide patient with dementia is admitted to the unit and is very agitated during the night - CORRECT ANSWER put patient in room next to nursing station LPN finds schizophrenic patient sitting and talking alone - CORRECT ANSWER PN should ask if patient is hearing voices HIV patient received Rifampin, Gentamicin and Isoniazid which one will cause ringing of the ear? - CORRECT ANSWER gentamicin to lower fear of separation for 2 year old nurse can - CORRECT ANSWER encourage parent to move in what can cause hypertension in. client - CORRECT ANSWER eating salty snack and chewing tobacco There was a picture of SCD (sequential compression device) placement and picking the picture with the correct placement - CORRECT ANSWER google some pictures of what placement looks like. SCD should be placed on calf than flat side folded first around shin and than part with 3 folds over the flat. Picture will make more sense There was a question about a patient going into surgery who has diabetes do you give them insulin or not? - CORRECT ANSWER do not give a patient insulin before going into surgery Patient states that he does not want to have pancreas cancer so for now he will switch to smokeless devices - CORRECT ANSWER nurse should instruct risk about smokeless devices also signs of hyperthyroidism - CORRECT ANSWER apprehensive agitated and irritable budging eyes (GRAVES DISEASE) weightloss poor tolerance to heat tachycardia signs of hypothyroidism - CORRECT ANSWER lethargic poor appetite dry cool skin sluggish know postoperative care for parathyroidectomy - CORRECT ANSWER -complications are airway obstruction and hypocalcemia -be alert for tetany a tingling around the mouth and fingers and can be treated with calcium keep head elevated UAP delegations - CORRECT ANSWER -applying a condom catheter -applying a hearing aid -applying cold packs -assisting to deep breath and cough -blood glucose monitoring -collecting specimens -emptying drainage containers -giving a sitz bath -vaginal douche -recording intake/output -removing a Foley catheter -taking specimens to the lab hyperparathyroidism - CORRECT ANSWER -administer furosemide (lasix) -monitor positive signs of Trousseaus Chvosteks sign -monitor for changes in the voice pattern and hoarseness hypoparathyroidism - CORRECT ANSWER -can occur following a thyroidectomy because of the removal parathyroid tissue -provide high calcium and low phosphorus -reinforce taking vitamin d with aiding in the absorption of calcium monitor for signs of hypocalcemia including tetany and numbness and tingling in the face