HESI TERM 2 EXIT
1. A 16-year old client who has admitted to the psychiatric unit. Which
nursing intervention is MOST important for the practical nurse (PN) to
implement?
1. Do not leave the client alone
2. Assess the family history for depression
3. Obtain information about previous suicide attempts
4. Limit visitation until the clients vital signs are stable Ans: ? Do not leave
the client alone
2. The practical nurse is initiating a new prescription for nitroglycerin
trans- dermal patch for a client with angina pectoris. What action has the
highest priority in preventing tolerance to the nitrogylcerin?
1. Shave the chest hairs to ensure adequate skin contact
2. Label the patch with date, time, and nurse's initials
3. emove the patch at bedtime as prescribed Ans: Remove the patch at
bedtime as prescribed
3. Constant observation is an intervention included in the plan of care for a
female client with dementia because she is at risk for falls. When she walks to
the door and asks to leave, the practice nurse (PN) is unable to convince her
to return to her room. Which action should the PN take?
1. Allow the client 10 minutes to stand by the door
2. Request assistance to remove the client from the exit
,3. Distract the client by offering to walk with her
4. Administer a PRN prescription for agitation Ans: Distract the client by
offering to walk with her
4. A female client with obsessive compulsive disorder is admitted to the
hospital for a cardiac catheterization. The afternoons before the procedure,
the client begins to keep detailed notes if the nursing care she is receiving. At
bedtime, she shows the list to the practical nurse (PN). Which action should
the PN implement?
1. Ask the client to explain why she is writing down each nursing task
2. Encourage her to express her feelings about the upcoming procedure
3. Recommend strategies to control her obsessive compulsive behaviors
4. Explain the rationales for each nursing responsibilities Ans: Encourage
her to express her feelings about the upcoming procedure
5. An 18-year-old female client who was released 3 weeks ago following two
months of treatments for anorexia returns to the HCP office for a follow-
up visit. Which statement indicates to the PN that the client is recovering
and coping after treatment for anorexia nervous?
1. "If I don't go to college scholarship my parents will be very disappointed
in me"
, 2. "My parents attempt to smother me, but I will not allow them to make
my decisions."
3. "I know that I am fat and I plan to lose at least ten more pounds."
4. "I will not binge eat, vomit after I eat, or take laxatives or diuretics."
Ans: "I will not binge eat, vomit after I eat, or take laxatives or diuretics."
6. A resident in a long term care facility is to receive fluconazole 150mg
PO daily for seven days. The medication is available in 50mg tablets and
the medication needs to be given for four more days. To ensure that there
are sufficient tablets for the remaining four days, the practical nurse should
confirm that there are how many remaining tablets? Ans: 12
7. While changing the dressing of a clients abdominal incision, the practical
nurse observes a large amount of purulent drainage on the dressing. Which
data should the PN collect first?
1. Assess the degree of skin elasticity
2. determine the client's oxygen saturation
3. measure the client's body temperature
4. observe the appearance of the incision Ans: ? observe the appearance
of the incision
8. A young male adult who suffered a concussion a week ago in a motor
vehicle collision comes to the clinic because he is unable to sleep. When
the practical nurse enters the examination room, the client is startled
and is hyper-vigilant. After reassuring the client, which action should
1. A 16-year old client who has admitted to the psychiatric unit. Which
nursing intervention is MOST important for the practical nurse (PN) to
implement?
1. Do not leave the client alone
2. Assess the family history for depression
3. Obtain information about previous suicide attempts
4. Limit visitation until the clients vital signs are stable Ans: ? Do not leave
the client alone
2. The practical nurse is initiating a new prescription for nitroglycerin
trans- dermal patch for a client with angina pectoris. What action has the
highest priority in preventing tolerance to the nitrogylcerin?
1. Shave the chest hairs to ensure adequate skin contact
2. Label the patch with date, time, and nurse's initials
3. emove the patch at bedtime as prescribed Ans: Remove the patch at
bedtime as prescribed
3. Constant observation is an intervention included in the plan of care for a
female client with dementia because she is at risk for falls. When she walks to
the door and asks to leave, the practice nurse (PN) is unable to convince her
to return to her room. Which action should the PN take?
1. Allow the client 10 minutes to stand by the door
2. Request assistance to remove the client from the exit
,3. Distract the client by offering to walk with her
4. Administer a PRN prescription for agitation Ans: Distract the client by
offering to walk with her
4. A female client with obsessive compulsive disorder is admitted to the
hospital for a cardiac catheterization. The afternoons before the procedure,
the client begins to keep detailed notes if the nursing care she is receiving. At
bedtime, she shows the list to the practical nurse (PN). Which action should
the PN implement?
1. Ask the client to explain why she is writing down each nursing task
2. Encourage her to express her feelings about the upcoming procedure
3. Recommend strategies to control her obsessive compulsive behaviors
4. Explain the rationales for each nursing responsibilities Ans: Encourage
her to express her feelings about the upcoming procedure
5. An 18-year-old female client who was released 3 weeks ago following two
months of treatments for anorexia returns to the HCP office for a follow-
up visit. Which statement indicates to the PN that the client is recovering
and coping after treatment for anorexia nervous?
1. "If I don't go to college scholarship my parents will be very disappointed
in me"
, 2. "My parents attempt to smother me, but I will not allow them to make
my decisions."
3. "I know that I am fat and I plan to lose at least ten more pounds."
4. "I will not binge eat, vomit after I eat, or take laxatives or diuretics."
Ans: "I will not binge eat, vomit after I eat, or take laxatives or diuretics."
6. A resident in a long term care facility is to receive fluconazole 150mg
PO daily for seven days. The medication is available in 50mg tablets and
the medication needs to be given for four more days. To ensure that there
are sufficient tablets for the remaining four days, the practical nurse should
confirm that there are how many remaining tablets? Ans: 12
7. While changing the dressing of a clients abdominal incision, the practical
nurse observes a large amount of purulent drainage on the dressing. Which
data should the PN collect first?
1. Assess the degree of skin elasticity
2. determine the client's oxygen saturation
3. measure the client's body temperature
4. observe the appearance of the incision Ans: ? observe the appearance
of the incision
8. A young male adult who suffered a concussion a week ago in a motor
vehicle collision comes to the clinic because he is unable to sleep. When
the practical nurse enters the examination room, the client is startled
and is hyper-vigilant. After reassuring the client, which action should
