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Examen

HESI VN/ PN EXIT Exam 100% Verified

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HESI VN/ PN EXIT Exam 2022/ 2023 100% Verified

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HESI VN/ PN EXIT
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HESI VN/ PN EXIT
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HESI VN/ PN EXIT

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Subido en
18 de junio de 2023
Número de páginas
30
Escrito en
2022/2023
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Examen
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HESI VN/ PN EXIT Exam
2022/ 2023
100% Verified

, HESI VN/ PN EXIT Exam 2022/ 2023
1. When obtaining a capillary blood sample for glucose measurement, which intervention
should the practical nurse (PN) implement?

a. Grasp the subcutaneous tissue and pull upward
b. Remove any nail polish from the fingernails
c. Determine which finger was used previously
d. Apply a tourniquet above the antecubital fossa

Rationale: Using another site than a previously accessed finger pad reduces repeated trauma
to the tissue and capillary supply in the distal finger where the blood sample is taken.

2. The practical nurse (PN) is assisting a client to cough and deep breathe following surgery.
To facilitate effective coughing, the PN should assist the client to assume which position?

a. Lying prone with the head turned to one side
b. Leaning forward over the bedside table
c. Left-lateral with pillow between flexed knees
d. Sitting on the side of bed with feet flat on the floor

Rationale: Sitting upright facilitates diaphragm excursion and enhances thoracic and
abdominal expansion.

3. An older female adult who was admitted to a long-term care facility yesterday is
confused about what day of the week it is. Her history does not indicate that she was
confused prior to admission. What action should the practical nurse (PN) take?

a. Remind the client what day of the week it is
b. Document the client’s loss of memory in the record
c. Notify the family of the changes in the client’s condition
d. Encourage the client to rest during the day

Rationale: Relocation often results in confusion among elderly clients during times of
adjustment to new surroundings. The PN should remind the client which day of the week it is
when she forgets or becomes confused. The other actions are not indicated at this time for
relocation or stress.

4. The practical nurse (PN) learns that a client who is receiving chemotherapy has
developed stomatitis. Which information should the PN obtain from the client during a
focused assessment?

a. Frequency of bowel movements
b. Blood pressure while standing
c. Ability to swallow
d. Urinary output

, Rationale: Stomatitis or inflammation of the oral mucosa can cause pain and result in
difficulty in swallowing. The PN should gather information related to the client’s ability to
swallow.

5. The practical nurse (PN) is assigned to care for a client who had an endoscopic
procedure in which the local anesthetic was sprayed on the throat. Which priority action
should the PN include in the clients plan of care?

a. Instruct the client to speak
b. Inquire about a sore throat
c. Observe for belching
d. Assess the gag reflex

6. A client receives ondansetron prior to a chemotherapy treatment. How should the
practical nurse evaluate the effectiveness of the medication?

a. Determine if the client feels calm and relaxed before the treatment
b. Monitor the client for nausea and vomiting following the treatment
c. Observe the client for signs of pain or discomfort during the treatment
d. Assess for changes in vital signs during and after the treatment

Rationale: Ondansetron is an antiemetic administered prior to chemotherapy to prevent post-
treatment nausea and vomiting. The other actions do not evaluate the desired effect of
ondansetron.

7. When gathering data about a client with dark skin tones, which site should the practical
nurse (PN) observe?

a. Finger and toenails
b. Sclera and mucous membranes
c. Forehead and face
d. Hands and feet

8. An older client who had a colon resection 8 days ago is straining at stool. The practical
nurse (PN) observes sudden spillage of serosanguinous drainage from the client's wound
followed by appearance of bowel on the skin. Which complication has occurred?

a. Evisceration
b. Dehiscence
c. Hemorrhage
d. Infection

Rationale: Evisceration is the complete separation of a wound with protrusion of the viscera,
which usually occurs 7-10 days postoperatively.

9. A client who is being cared for in her home has a low serum sodium level of 125 mEq/L.
To determine the cause of this value, which information should the practical nurse (PN)
request from the client?
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