PN Hesi Fundamentals Practice

Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status? - Daily body weight The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing? - Remove all four sides by moving to the center of the incision. A male client ho is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." Which action should the PN implement first? - Assist the client to a supine position. An older client who is unable to swallow is receiving continuous NGT feeding. Before administering medications through the NGT, what action should the practical nurse implement? - Flush the feeding tube with water. Which action should the practical nurse implement to help a male client cope with his fear as he approaches death? - Hold the client's hand and tell him he is no alone. The practical nurse is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement? - Obtain a soft-bristle brush for the client. The practical nurse is caring for a client who is admitted with influenza and vomiting for 3 days. The clients skin turbot is poor and oral mucous membranes are dry. Which finding is most important for the PN to report to the charge nurse? - Hypotension and tachycardia Which food should the practical nurse recommend for a client to increase the dietary intake of potassium? - Baked potatoes When irrigating the external ear canals of an older adult client, which action should the PN use to soften dry cerumen for removal? - Instill mineral oil in the external auditory canal overnight before irrigation. An older female state the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse take? - Check the written prescription to verify the medication Which action should the PN implement when administering a subcutaneous injection to a client who weighs 325 pounds? - Select a needle with a longer shaft Which intervention provides confirmation of NGT placement before NGT feedings are started? - X-ray of the abdomen An older male client who is incontinent receives a prescription for a condom catheter. Which steps should the PN implement when applying the external catheter. - Wrap the adhesive strip in a spiral around the penis Apply skin prep to the penile shaft and allow to dry Leave 1-2 inches between the tip of the penis and condom catheter Acetaminophen is prescribed for an unconscious client with a temp of 104' F. Which route should the PN plan to administer this medication? - Rectal An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the PN that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first? - Digitally assess for impacted stool. The PN is adding tap water to several medication for administration via feeding tube. Which preparation should the PN administer without delay? - Time release capsule Which action should the PN follow when applying an elasticize bandage to a client's leg? - Overlap turns of the bandage equally The PN obtains an elevated blood pressure reading for an older male client is is alert. When the PN offer the client his morning blood pressure medication, he refuses to take it. What action should the PN take? - Explain the importance of routine use of antihypertensives. What position should the PN place client in who is receiving an enteral tube feeding? - Supine with the head of bed elevated to 30-45 degrees. The PN is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site? - 1 inch An older male client tells the PN that his religion does not permit him to bathe daily. How should the PN respond? - Request that the client clarify his religious beliefs about bathing. The PN identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN? - Bowel movements decreases to one every third day. A client is prescribed a medication that is labeled as a sustained released (SR). What action should the PN implement when administering this drug form? - Do not crush or dissolve the table or capsule contents The practical nurse is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. What nursing action should the PN take? - Mark the outlined area of drainage with date, time and initials A client with gastroenteritis, nausea and vomiting is currently on NPO status. The healthcare provider prescribed oral intake to be advanced as towered. Which fluid should the PN offer first? - Water Which time frame should the PN res position a client? - Every 2 hours While taking an adult's vital signs, the PN notes an irregular radial pulse. What action should the PN implement to obtain the most accurate assessment? - Perform an apical-radial pulse assessment with another nurse The practical nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase granulation tissue will develop within 2 weeks," which intervention should the PN implement.? - Irrigation of the wound with sterile normal saline A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the PN implement to maximize the client's oxygenation? - Provide oxygen during rest periods between suctioning. An older client who complains of dry mouth is having trouble swallowing pills. What action should the PN take when administering an enter-coated tablet? - Place the whole tablet in a spoonful of pudding. The PN is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client? - Soybeans The PN observes a client who begins to choke during a meal. After determining that the client cannot speak, what action should the PN implement? - Place a fist halfway between the xiphoid process and umbilicus. The practical nurse is irrigation a clients indwelling catheter. After injecting sterile solution as prescribed what action should the PN implement? - Unclamped the tubing and lower the collection bag. The PN hears breath sounds that are short, popping, and discontinuous on inspiration when auscultations a clients lungs. Which description should the PN document in the clients record? - Crackles auscultated A male client is upset with the healthcare providers recommendation that he should consent to an above-knee amputation. He tells the PN, "If they want to cut off my left, they should just shoot me instead." How should the PN respond? - As the client how the surgery might effect his lifestyle Which findings indicates to the PN that an older client who is receiving intravenous therapy is experiencing fluid overload? - Crackles in the lungs Which action should the PN implement when supporting an older client who is afraid of dying? - Use open-ended questions to encourage the client to share feelings A client is receiving a continuous tube feeding. While checking the gastric residual volume, the PN aspirated 150 mL of gastric contents. What action should the PN take? - Return all aspirated fluid to the stomach followed with water and consult agency policy.