HESI Fundamentals

In planning care for an older client on bed rest, which intervention should the practical nurse include in the prevention of pressure ulcers?

Elevate the head of the bed less that 30 degrees.

An older female recently diagnosed with coronary artery disease (CAD) cooks at home using saturated fats, Which intervention should the practical nurse implement to help the client reduce modifiable risk factor(s)?

Encourage food preparation with various vegetable oils.

The practical nurse (PN) contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints?

To ensure the client's safety when the benefits outweigh the risk.

A client's indwelling urinary catheter is removed at 9:30 AM. The practical nurse (PN) assesses the client every two hours for the desire to void. Which documented assessment requires further intervention by the PN?

5:30 pm: unable to void.

Which action should the practical nurse (PN) take when drawing medication from an ampule?

Aspirate with a filter needle and syringe.

An older female states that the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse (PN) take?

Check the written prescription to verify the medication.

Which intervention should the practical nurse (PN) implement to reduce the incidence of urinary tract infections in a client with an indwelling catheter?

Cleanse perineum area with soap and water BID and PRN.

An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the practical nurse (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.

Which time frame should the practical nurse (PN) reposition a client?

Every 2 hours.

Which intervention should the practical nurse (PN) use to prevent obstruction of a gastric feeding tube?

Obtain a prescription for a liquid drug form instead of crushing tablets.

The practical nurse (PN) 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.

Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client's leg?

Overlap turns of the bandage equally.

Acetaminophen is prescribed for an unconscious client with a temperature of 104 F. Which route should the practical nurse (PN) plan to administer this medication?

Rectal.

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.

What nutritional information should the PN provide a client with heart failure (HF)?

Restrict dietary sodium intake.

The practical nurse (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

What position should the practical nurse (PN) place a client in who is receiving an enteral tube feeding?

Supine with the head of the bed elevated 30 to 45 degrees.

During insertion of a nasogastric tube (NGT) into the right nares, the client starts to cough. Which action should the practical nurse (PN) implement?

Withdraw the NGT to the oral pharynx, repostion client's head and reinsert.

An older male client who is incontinent receives a prescription for a condom catheter. Which step(s) should the practical nurse implement when applying the external catheter? (select all that apply)

Wrap the adhesive strip in a spiral around the penis. Apply skin prep to the penile shaft and allow to dry. Leave 1 to 2 inches between the tip of the penis and condom catheter.

The practical nurse (PN) is applying a dry, sterile dressing to a client's abdominal wound. Which allergy should the PN verify with the client?

tape.

The practical nurse (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.

A client is receiving a Mantouz test for tuberculosis screening. Which angle should the practical nurse (PN) insert the needle for injection?

15 degrees.

The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers 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.

The practical nurse (PN) 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.

Which technique should the practical nurse (PN) use to most accurately assess a client's baseline blood pressure during a routine health examination?

Measure the pressure in each arm while the client sits with the arm supported at heart level.

A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. he client expresses fear about becoming addicted to these drugs. What information should the practical nurse (PN) provide?

Prescribed opiates for cancer pain relief improve quality of life.

A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client's oxygenation?

Provide oxygen during rest periods between suctioning.

Which growth and developmental characteristic should the practical nurse (PN) consider when discussing spirituality with an adolescent client?

Questions religious practices and values.

Which intervention provides confirmation of nasogastric tube (NGT) placement before NGT feedings are started?

Flat plate x-ray of the abdomen.

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 feedings?

Guilt.

The practical nurse (PN) is caring for a client who is admitted with influenza and vomiting for 3 days. The client's skin turgor is poor and oral mucous membranes are dry. Which finding is most important for the practical nurse (PN) to report to the charge nurse?

Hypotension and tachycardia

A client whose diet is low in fiber is at risk for which condition?

Colon cancer.

An older client is receiving nasogastric tube (NGT) feedings for several days

Abdominal distention and nausea.

Which intervention should the practical nurse (PN) implement to help a client cope effectively with chronic pain?

Encourage using relaxation techniques.

Following a cholecystectomy, a client asks the practical nurse (PN) about dietary restrictions that may need to be followed. Which diet should the PN recommend?

A well-balanced diet with no other restrictions.

A client who has a pressure-relieving mattress overlay is mobilized to a chair and imprints of the clients buttocks, heels, and scapula are evident on the mattress overlay. What action should the practical nurse implement?

Apply a different pressure relieving device and assess its effectiveness for this client.

A male client is upset with the healthcare provider's recommendation that he should consent to an above-knee amputation. He tells the practical nurse (PN), if they want to cut off my leg, they should just shoot me instead. How should the PN respond?

Ask the client how the surgery might effect his lifestyle.

The male client who 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.

Which food should the practical nurse (PN) recommend for a client to increase the dietary intake of potassium.

Baked potato.

The practical nurse (PN) identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN?

Bowel movements decrease to one every third day.

Which client group is most likely to experience a therapeutic response from therapeutic touch?

Clients with headaches.

Which action by the practical nurse (PN) demonstrates the value of dignity in client care?

Closes the door and covers the client during a bath.

The practical nurse (PN) hears breath sounds that are short, popping, and discontinuous on inspiration when auscultating a client's lungs. Which description should the PN document in the client's record?

Crackles auscultated.

Which finding indicates to the practical nurse (PN) that an older client who is receiving intravenous therapy is experiencing fluid overload?

Crackles in the lung fields.

Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status?

Daily body weight.

The practical nurse (PN) identifies a client's need for spiritual support. What is the first action the PN should take?

Determine the client's perceptions and belief system.

An older client who has been on bed rest in not eating well and is exhibiting abdominal distension, cramping, and is passing small amounts of liquid stool. Which prescribed action is most important for the practical nurse (PN) to implement?

Digitally remove a fecal impaction.

When irrigating the eyes of a client, which action should the practical nurse implement?

Direct the irrigation flow from the inner canthus to the outter canthus of the affected eye.

A client is prescribed a medication that is labeled as a sustained released (SR). What action should the practical nurse (PN) implement when administering this drug form?

Do not crush or dissolve the tablet or capsule contents.

The practical nurse (PN) is obtaining the vital signs for a client who has a urinary tract infection with Methicillin-resistant Staphylococcus Aureus (MRSA). How should the PN proceed?

Don a gown and gloves before entering the room.

An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy for the practical nurse (PN) to implement for the client's incontinence?

Establish a 2-hour voiding schedule.

The practical nurse (PN) is obtaining information for a male client's psychosocial assessment. Which action should the PN implement first?

Establish a therapeutic relationship.

An older client who is unable to swallow is receiving continuous nasogastric tube (NGT) feeding. Before administering medication through the NGT, what action should the practical nurse (PN) implement?

Flush the feeding tube with water.

A family member of a dying client asks the practical nurse (PN) if the client knows the family is at the bedside. The PN explains that which of the five senses persists the longest during the dying process?

Hearing

A male Native American client with tuberculosis is visiting a health care clinic for follow up treatment. During the interview, the practical nurse (PN) notices that the client keeps his eyes on the floor and does not make eye contact. How should the PN interpret this client's behavior?

His culture finds sustained eye contact rude or disrespectful.

Which action should the practical nurse (PN) implement to help a male client cope with his fear as he approaches death?

Hold the client's hand and tell him he is not alone.

Which technique should the practical nurse use to give a Z-tract intramuscular (IM) injection?

Inject the medication into the dorsal gluteal site.

When irrigating the external ear canals of an older adult client, which action should the practical nurse (PN) use to soften dry cerumen for removal?

Instill mineral oil in the external auditory canal overnight before irrigation.

The practical nurse (PN) is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, and increase in granulation tissue development within two weeks, which intervention should the PN implement?

Irrigate wound with sterile normal saline.

An 80 year old male client who has arthritis and is having difficulty walking, tells the practical nurse (PN), "It's awful to be old, It seems as thought every day is a struggle. No one cares about an old person." What is the best response for the PN to provide?

It sounds as though you're having a difficult time. Tell me about it.

A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the practical nurse's priority intervention?

Obtain orthostatic blood pressures.

The practical nurse (PN) observes a client who begins to choke during a meal. determining that the client cannot speak, what action should the PN implement?

Place a fist halfway between the xiphoid process and umbilicus.

The healthcare provider prescribes a cleansing enema for an adult prior to bowel surgery. Which intervention(s) should the practical nurse implement to ensure adequate bowel cleansing? (Select all that apply)

Place the client on the left side in Sim's position. Use enema fluid that is near 105 F (40.4 C). Instill 500 mL to 1,000 mL fluids slowly. Raise the enema container 20 inches above anus. Encourage the client to retain fluid 10 to 15 minutes.

An older client who complains of dry mouth is having trouble swallowing pills. What action should the practical nurse take when administering an enteric-coated tablet?

Place the whole tablet in a spoonful of pudding.

While taking an adult's vital signs, the practical nurse (PN) notes an irregular radial pulse, What action should the PN implement to obtain the most accurate assessment?

Preform an apical-radial pulse assessment with another nurse.

The practical nurse (PN) is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the client's comfort?

Preform oral hygiene frequently.

An older male client tells the practical nurse (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 client is receiving a continuous tube feeding. While checking the gastric residual volume, the practical nurse (PN) aspirates 150 mL of gastric contents. What action should the PN take?

Return all the aspirated contents to the stomach followed with water and consult the agency policy.

Which information should the practical nurse provide a client who is selecting a site for self-injection of insulin?

Rotate sites within the same location for a week before choosing a new location.

The practical nurse (PN) is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in this client?

The lips and mucous membranes of a client with dark skin are dusky in color.

A client is receiving a daily prescription for furosemide (Lasix) 40 mg PO, but is unable to swallow. The practical nurse (PN) should consult with the healthcare provider about which component of the prescription?

The route of administration.

The practical nurse (PN) is adding tap water to several medications for administration via feeding tube. Which preparation should the PN administer without delay?

Timed release capsule.

The practical nurse (PN) is irrigation a client's indwelling urinary catheter, After injection normal saline as prescribed, what action should the PN implement?

Unclamp the tubing and lower the collection bag.

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

Use a pain scale to describe the intensity.

Which action should the practical nurse (PN) implement when supporting an older client who is afraid of dying?

Use open-ended questions to encourage the client to share feelings.

The practical nurse (PN) is preparing to reconstitute a drug from powder for for IM administration. Which step should the PN implement first?

Verify the drug with the medication administration record (MAR).

The practical nurse is administering scheduled morning medications to a client who states, I haven't seen that pill before. Are you sure it's correct? Which action should the PN take?

Verify the prescription before administrating the medication.

A client with gastroenteritis, nausea, and vomiting is currently on Nothing by mouth (NPO) status. The healthcare provider prescribes oral intake to be advanced as tolerated. Which fluid should the practical nurse offer first?

Water.

A young woman, who is the primary caregiver for her mother who has Alzheimer's disease, tells the practical nurse (PN), "Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." What response should the PN offer?

What you do to cope with these feelings?

Which action should the practical nurse (PN) implement when administering a subcutaneous injection to a client who weighs 325 pounds?

select a needle with a longer shaft.

Which food should the practical nurse (PN) recommend to a client as a source of complete protein?

Eggs.

Which position is best for the practical nurse to place the client during administration of a rectal suppository for constipation?

Left Sim's position with upper leg flexed.