hesi questions
The PN is caring for a client with Chronic kidney disease (CKD). What information should the PN reinforce about medication management?
Antihypertensive drugs should always be used as directed
An older male client who drove himself to the ER clinic with chest pain placed on a cardiac monitor with nasal cannula at 2l/min as an IV access is obtained. Which intervention should the PN implement first?
Apply telemetry electrodes to the clients chest
Which intervention is most important for the PN to implement to decrease the number of falls for a client in a long term facility?
Ask about the need to use the bathroom
The PN is talking with an adult male client who says that he is satisfied with how he has lived his life. According to Erikson's staging theory, this client is in which stage?
Integrity versus despair
A client is receiving an IV solution of sodium chloride 0.9% NS 250 ml with amiodarone (Cordarone) 1 g at 17ml/hr. How many mg/min of amiodarone is infusing?
1.1 1g=1000mg 1000mg : 250 ml :: X mg 1ml 250X= 1000 so X= 4mg/ml 60 min/hr 17 ml/hr X 4 mg/ml = 68/60min = 1.13 rounded to nearest tenth 1.1 mg/min
A client is receiving D5W 1000 ml at 75 ml/hr. The PN hangs the bag of IV fluids at 0300. At what time, based on the 24 hr clock should the infusion be completed?
1620 1000/75= 13.3 hours (13 hrs 20 minutes) 0300 + 13hrs 20min = 1620
A client who has a GT feeding is receiving 3/4 strength ensure 240 ml every 6 hours. Full strength ensure is available in a 240 ml can. The PN should use how many ml of ensure to prepare the feeding? Enter numeric value only, if rounding round to the nearest whole number
180 240 ml/ 0.75 = 180
A client with mycobacterium Adium complex (MAC) is receiving an infusion of 5% dextrose in water with amikacin (Amikin) 0.572 g/100 ml every 12 hours. The PN prepares the dose of amilacin using a vial labeled, 250 mg/ml. How many ml should the PN add to the infusion? Enter numeric value only, if rounding is required round to the nearest tenth.
2.3 1 g = 1000 mg 1000mg x 0.572 = 572mg D/HXQ 572/250 x 1 = 2.288 or 2.3 ml
The PN is preparing to administer vancomycin (Vancocin) 750 mg in 250 ml of D5W, and plans to administer the dosage over 75 minutes. The secondary infusion pump should be programmed to administer how many ml/hr? Enter numeric value only, if rounding round to the nearest whole number
200 250ml of antibiotics is to infuse over 75 minutes or 1.25 hours 250 ml divided by 1.25 hours equals = 200 ml/hr
A client who weighs 21.1 kg is receiving calcium chloride PO. The drug literature recommends 20 mg/kg/dose. How many mg should the PN determine is recommended dose for this client?
20mg/kg/dose 21.1 kg x 20 mg/ 1mg = 422
A client with a forearm laceration arrives in the clinic applying direct pressure with a clean wash cloth. The PN notes that the washcloth is saturated with blood. What action should the PN implement?
Apply digital pressure to the arm above the injury
The HCP prescribes a continuous infusion of dextrose 5% in water with isoproterenol Isuprel) 2mg in 500ml at a rate of 5mcg/min for a client with cardiac arrhythmia. The PN should program the infusion pump to deliver how many ml/hr?
75 1mg = 1000mcg 2mg = 2000mcg 2000mcg/5 500/X X= 1.25 ml/min 1.25 ml x 60 min = 75ml/hr
A client who weighs 79lbs. Is receiving clomipramine (Anafranil) PO. The PN refers to the published drug literature which recommended the dose of 3mg/kg/day. How many mg should the PN determine is the recommended dose for this client? Enter numerical value only
79lbs/2.2= 35.9090kg 35.9090kg x 3 mg= 107.7 or 108mg/day
The PN is administering scheduled morning medication to a client who states I haven't seen that pill before. Are you sure its correct? Which action should the PN take?
Verify the prescription before administering the medication
The PN is caring for a client following aortic aneurysm resection with graft placement. Which lab finding should the PN report to the charge nurse immediately?
BUN 25mg/dl, creatine 2.0 mg/dl
A client has collapsed while getting out of bed, has no pulse, and is not breathing. After calling for help and an AED, which action should the PN take?
Begin cardiac compressions
The PN is reviewing the electronic medication administration record (MAR) for a client who receives warfarin (Coumadin) daily. A notation on the MAR for yesterday is marked "hold" for the daily Coumadin dose and no other directions are noted for todays dose. What action should the PN take?
Check prescription
The PN stresses to a female client the importance of osteoporosis prevention. Which foods should the PN recommend the client to include in her diet?
Canned tuna
The PN assigns the UAP to take vital signs for a client with bacterial meningitis. Which findings should the PN direct the UAP to report immediately?
Change in consciousness
The nursing staff team includes the RN, PN and UAP. Which task should be assigned to the PN?
Changing decubitus dressing for an immobile client
Which assessment should the PN make to best evaluate a clients fluid status?
Daily body weight
What action should the PN implement to facilitate speech for a client who has a fenestrated tracheostomy tube?
Determine the clients ability to swallow
The PN is reviewing a meal plan of foods rich in riboflavin for aprimigravida client. Which foods should the PN suggest that the client eat at least 2 servings daily?
Enriched cereals
A client admitted with major depression is placed on suicide precautions. While orienting the client to the unit, which activity should the PN implement?
Explain the purpose and implantation of suicide precautions
When monitoring a newborn, which observation should the PN report to the HCP?
Heart rate of 110 bpm Normal range for newborns 120-160
The PN identifies four assigned clients that need additional follow up care. Which client issue has the highest priority?
Infiltrated IV secondary medication
The PN is planning morning care for a client with GI bleeding and a hemoglobin level of 8.1 g/dl who is scheduled to receive a unit of PRBC. Which action should the PN take?
Initiate serial vital signs before and during the transfusion
The PN is caring for a client who had a total hip replacement yesterday. Which task should the PN assign to the UAP?
Remind the client to use the incentive spirometer
Which action should the PN implement when administering a subcut injection to a client who weighs 325lbs?
Select needle with longer shaft
A client is 24 hours post endoscopic retrograde cholangiopancreatography (ERCP) for cholelithiasis. Which findings should the PN report to the HCP?
Serum amylase elevation 3 times above the normal levels
A male client returns to the surgical nursing unit from post anesthesia care unit and still drowsy. The PN uses verbal stimuli to keep the client responsive. In what position should the PN place the client until he is more reactive?
Side lying
The PN is changing the ileostomy collection bag on a client who is 6 days postoperative for a total colectomy. Which finding requires additional action by the PN?
Skin maceration around the stoma
The PN is assessing a client with dark skin who is respiratory distress. Which client response should the PN evaluate to determine cyanosis in this client?
The lips and mucosa membrane of the client with dark skin are dusky in color
The PN is adding tap water to several medications for administration via feeding tube. Which preparation should the PN administer without delay?
Timed release capsule
A client schedule for surgery is to receive an IV infusion of 0.9% sodium chloride with prochlorperazine edisylate (Compazine) 10mg/50 ml over 30 minutes. The PN should program the infusion pump to deliver how many ml/hr?
100 50/x : 30/60 3000 = 15x X= 100 ml
The PN obtains a clients oral temp of 38C. What is it in Fahrenheit?
100.4 1.8 x 32 = 68.4 + 32 = 100.4
A client who weighs 159lbs is receiving ganciclovir (Cytovene) IV. The PN refers to the published drug literature which recommends the dose of 5 mg/kg/dose. What dose in mg should the PN determine is the recommended dose for this client? Enter numeric value only, if rounded is required round to the nearest whole number
159lbs/2.2 = 72.1212kg x 5 mg = 360.61 or 361 mg
A client is receiving ethambutol hydrochloride (Myambutol) 1.6 g PO daily. How many mg should the PN administer?
1mg = 0.001 g 1.60 g x 1mg/0.001 grams = 1600mg
The PN is giving iron dextran (Imferon) 250mg IM using Z track method to a client with anemia. Which needle should the PN select for this injection?
2 inch, 19 gauge needle
A client who weighs 70 lbs receives a prescription for phenytoin (Dilantin) PO. The PN refers to the published drugs literature which recommends the dose of 10mg/kg/day. How many mg should the PN determine is recommended dose for this client?
318 70/2.2 = 31.8181 31.8181 x 10mg = 318
A child who weighs 32lbs receives a prescription for a moxicillin with clavulanate (Augmentin) 194 mg PO every 8 hours. The recommended dose is 40mg/kg/day, and a bottle contains 125 mg/5ml. How many mg should the child receive in a 24 hr period? Enter numeric value only, if rounded is required round to the nearest tenth.
32/2.2= 14.54kg 40mg x 14.54g/day = 581.81 or 582mg
A client is receiving an IV solution of 2 g of medication diluted in 100 ml of NS over a hour. How many mg of medication is the client receiving per minute?
33 2g = 2000mg 1 hour = 60 min 2000 mg/ 60min = 33.333/min round to nearest whole number 33
A client receiving dantrolene sodium (Dantrium) PO for malignant hyperthermia. The maximum safe dose is 8mg/kg/day in 4 divided doses. The client currently weighs 48.5kg. What is the maximum safe dose the PN should calculate?
48.5 x 8 = 388 388/4=97mg
A HCP prescribes a continuous infusion of 0.9% sodium chloride with pancuronion (Pavulon) 25 mg/250 ml at a rate 0.1 mg/kg/hr for a client with coronary artery bypass grafting. The client weighs 78kg. The PN should program the infusion pump to deliver how many ml/hr?
78 0.1 mg x 78 kg = 7.8 mg/hr 25 mg : 250 ml : 7.8 mg : X 25 mg/7.8 mg : 250 ml/X 25X = 1950 X= 78 ml/hr
For which client should the PN implement the Glasgow Coma Scale (GSC) assessment?
A client with a closed head injury who refuses to follow verbal commands GSC evaluates LOC
A male client in a skilled nursing home has metastatic cancer and has requested comfort care only. During the day, he does not want to get out of bed because he is too tired and weak to sit in a chair. He sleeps on and off all day and night, his position is changed every 2 hours, and he is comfortable on his pain control regimen. Which action should the PN implement at the beginning of the next day shift?
Assess his desire to get out of bed or remain in bed in a position of comfort
An older client is receiving NS at 83 ml/hour per gravity. At the end of shift assessments, the PN calculates the client's intake and output and determines that the infusion delivered 500 ml in the last hour. Which action should the PN take first?
Auscultation the lungs for crackles
The PN identifies several findings in an older adult client who is on prolonged bed rest. Which findings requires prompted action by the PN?
Bowel movements decrease to one every third day
The PN is caring for a female client with T2 spinal cord injury who is scheduled to begin intensive rehab. When the PN is assisting the client to transfer to a wheelchair, the client tells the PN she does not feel like getting up. The client complains of a sudden onset of a server throbbing headache. Which action should the PN implement first?
Check B/P
The PN is caring for a client with a chest tube and finds there is an absence of bubbling in the suction control chamber of the chest tube. What action should the PN take first?
Check the tube for leaks
Which finding in a newborn is most important for the PN to report?
Clinical jaundice evident on the forehead within 24 hours of birth
The PN is reviewing the schedule of yearly in service programs for competency based nursing care. Which criteria should the PN use in selecting programs that provide the best content to maintain nursing competency?
Complex procedures that are done only a few times a month
The PN is evaluating a clinet's self management of T1DM which findings provide the best parameter in the client's goals for the prevention of long term complications of DM?
Consistent hemoglobin A1C levels no greater than 7 %
A client who is ready for transfer from the PACU to postoperative unit continues to complain of pain at the incision site. What action should the PN implement?
Consult with the anesthesiologists for a prescribed dose of analgesic
A female client with terminal cancer is tearful and is becoming increasingly withdrawn from her family and the nursing staff. She refuses medications, treatments, food, and frequently says, "Why is God doing this to me?" Which intervention should the PN implement?
Contact her religious advisors to help her face death
The PN obtains an elevated B/P reading for an older male client who is alert. When the PN offers the client his morning B/P medication, he refuses to take it. What action should the PN take?
Explain the importance of routine use of Antihypertensives
A male client with coffee ground emesis is admitted with a hemoglobin of 10.2 g that is now 7.5 g/dl since admission. The client blood is typed and cross matched for 2 units of blood, and the HCP prescribes STAT administration of one unit. The client indicates to the PN that he wants to shower first. Which intervention should the PN implement?
Explain the need to start transfusion immediately
Which action should the PN implement to provide a sense of control to a toddler who is hospitalized?
Follow the child's usual routines for feeding and bedtime
The PN is reviewing with the parents of 6 month old baby about the dangers of botulism in food. Which food should the PN reinforce not feeding to their infant before the age of 12 months?
Honey
The Pn is caring for a client with pernicious anemia. What role does gastrin play in the disease?
Hormone that stimulates release of gastric juices
The PN is caring for a client who is receiving TPN. Which metabolic changes should the PN monitor the client during administration of TPN?
Hyperglycemia
The PN is caring for a client who is admitted with influenza and vomiting for 3 days. The clients skin turf or is poor and oral mucous membranes are dry. Which findings is most important for the PN to report to the charge nurse?
Hypotension and tachycardia
The PN assigns care of a client who is HIV + to a newly employed PN who states, " I cant take care of that client" how should the PN respond?
I don't understand your response. Please explain what you mean
The PN is checking client care equipment in the clinic for proper functionality. Which finding should the PN identity as a piece of equipment in need of repair?
IV pump alarms constantly
Which equipment malfunction should the PN report as having the highest risk to client safety?
IV pump screen does not light up and turn on
At the scene of a motor vehicle collision, the PN stops to render assistance to a victim who has bleeding injuries of the face and neck. Which action should the PN implement after establishing that the victim is unresponsive?
Immobilize the head and neck
In addition to lowering dietary sodium intake, which dietary changes should the PN encourage the client to make when learning to manage high blood pressure?
Include calcium and magnesium food sources daily
What action should the PN implement to improve the quality of sleep for a confused client?
Keep client awake during the day
The PN enters a clients room at 0900 to administer a heparin injection that is prescribed BID. The PT is in the middle of providing bedside therapy. What action should the PN take?
Leave with the medication and come back whenPT is finished
The PN is reinforcing diet teaching for a client with a simple goiter. Which foods should the PN recommend that the client eliminate from the diet?
Milk
Which action is most important for the PN to implement for a client who has a stage 1 pressure ulcer?
Monitor clients serum pre-albumin levels VitaminD for skin growth, = pre-albumin levels (D)
The HCP prescribes diltiazem ( Cardizem) 0.87 mg PO four times daily for an infant who weighs 22 lbs. The recommended maximum dose is 3.5 mg/kg/day. What action should the PN take?
Notify HCP
Which action should the PN follow when applying an elasticized bandage to a clients leg?
Overlap turns of the bandage equally
Regarding client confidentiality, what information represents the correct understanding by the PN of the guidelines set forth by HIPPA?
Past medical records for clients should be stored in a secured place
When caring for a client receiving TPN, which is the most important action?
Perform fingersticks glucose readings every 6 hours
Which disposable product should the PN place in biohazard container?
Peri-pads saturated with rubra lochia for a client who is one day post vaginal delivery
A male client scheduled for a total laryngectomy and radial neck dissection for cancer of the larynx asks the PN if he will ever be able to speak? Which response is best for the PN to provide?
Permanent removal of the voice box requires rehab for esophageal speech
An elderly client is in assistant living community is refusing to eat during meal time. The PN discovers that the client has several mouth ulcers. What types of food should the PN suggest to promote intake and healing of ulcers?
Poached eggs or scrambled eggs Proteins for tissue promotion
A client who is demonstrating violent behavior is restrained by personnel using a 4 man maneuver. Two days later, the PN sees that the client's arm is ecchymotic and mottled. What finding is most important for the PN to document?
Radial pulse
A male client who is receiving hospice care receives a prescription for radiation therapy for bone metastasis. The client tells the PN that he is on hospice. What information should the PN provide the client?
Radiation therapy provides pain relief and is palliative care measures
The PN is preparing a client about a stool guaiac test. Which foods should the PN tell the client to avoid 3 days prior to collecting the specimen for the test?
Raw broccoli foods High in iron
The PN is caring for a client in hospice who is comatose and needs vigorous suctioning. The PN is conflicted about implementing the needed care. What ethical action should the PN do first?
Speak to unit supervisor about the problem
Which task could the PN assign to UAP?
Verify ID arm bands when infant is left in moms room
An older client who takes digoxin (Lanoxin) daily calls the clinic about not feeling well. The new onset of which findings should the PN advise the client to come for a visit with the HCP?
Vomiting
Which client needs immediate action by the PN?
An older client who is climbing over the side rails
The PN receives report for 4 clients. While providing care, which client should the PN observe closely for hypernatremia?
An older client with quadriplegia who is disoriented today
The PN obtaining the vital signs for a client who has a UTI with MRSA. How should the PN proceed?
Don a gown and gloves before entering the room
Which site should the PN avoid when administering IM to toddlers?
Dorsalgluteal Sciatic damage
A child who is currently undergoing chemo for leukemia is brought to the clinic for a possible broken ankle. What priority action should the PN implement?
Place mask on child
The PN is caring for a client who is receiving chemo for cervical cancer and who is scheduled to go for a chest X-ray. Current labs are hemoglobin 10.0 g/dl, absolute neutrophil count of 500, platelets 120,000 mm3, and WBC 4000/mm3. What action should the PN implement first?
Place mask on client for transfer
The PN is preparing a client for surgery. Which criteria should the PN us to determine a clients nutritional status before the procedure?
Subjective Global Assessment
The PN is observing a newborns breathing pattern. Which breathing pattern the PN document as normal for this full term newborn?
Synchronized chest and abdominal movements
The HCP prescribes thiamine 0.03 g IM TID for a client with beriberi. Thiamine is available for injection 100 mg/ml. The PN should prepare to administer how many ml?
0.3 ml 1 g= 1000mg 0.03 x 1000 = 30mg 30mg/100 X 1ml = 0.3ml
The HCP prescribes ketorolac ( Toradol) 15mg IM for a client in pain. The available concentration is 30 mg/ml. How many ml should the PN administer?
0.5 ml 30ml = 1ml 15 = 0.5 ml
The PN is preparing to administer bumetanide (Bumex) 0.25 mg IV. The medication is available in a vial labeled 1mg/4ml. How many ml of medication should the PN administer?
1 0.25mg/1mg x4 ml = 1 ml
Which client is the best assignment for the PN?
An older adult client with dehydration who needs assistance with feeding PN scope of practice
A 49 y/o client with myasthenia gravis is receiving pyridostigmine (Mestinon) 126mg PO every 4 hours. The available form is 60mg in5 ml syrup. How many ml should the PN administer? If rounding is required, round to the nearest tenth
10.5 O/A x Q 126mg/ 60mg x 5 ml = 10.5 ml
A loading dose of acetylcysteine (mucomyst) 8g, which is available as 20% solution (200 mg acetylcysteine per ml) is prescribed by NGT for a client with acetaminophen toxicity. How many ml of diluent should be added to the medication to obtain a 1:4 concentration? Enter numeric value only. If rounded is required, round to the whole number
120 8g = 8000 mg 8000mg/ 200 mg x 1ml = 40ml of the 20% solution Dilute the 40ml to 1:4 40ml : x=160 ml - 40ml 0f 20% concentration = 120 ml
A client with dehydration receives a prescription for an IV of lactated ringers 1000ml to be administered over 8 hours. The PN should program the infusion pump to deliver how many ml/hr?
125 1000ml, 8hrs X 1hr 1000/X 8/1 X = 125 ml/hr
The PN is administering a 250 ml IV solution to be infused over 2 hours. How many ml/hr should the PN program the infusion pump? Enter numeric value only
125 250ml/. 2 hours = 125
Which client who arrives at urgent care clinic should be seen first by the PN?
13 y/o with asthma and just vomited following a spell of coughing
The HCP provider prescribes a continuous infusion of 5% dextrose in 0.45% solution chloride at 85 ml/hr. The IV administration set delivers 10gtt/ml. The PN should regulate the drop rate to deliver how many gtt/min. Enter numeric value only, if rounded is required round to the nearest whole number
14 Volume/60min x 10 gtt/ml = 14.16 14gtt/min
The HCP prescribes amoxicillin (AMOXIL) 600 mg PO every 8 hrs. The medication is available in a bottle labeled "Amoxicillin" suspension 200 mg/5ml how many ml should the PN administer for each dose?
15ml 600/200=3, 3X5ml = 15 ml
The HCP prescribes the adjustment of the IV hourly rate based on the NGT output q4hr for a client who had abdominal surgery yesterday. From 1200-1600 the NGT output was 240ml, and the IV of D5W0.45%NS was infusion at a rate of 100ml/hr. At 1600 the PN should regulate the IV to deliver how many ml/hr to repair this fluid loss?
160 240/4hrs = 60 60 ml NGT output for 1 hr 100 + 60 = 160
The PN is preparing a tube feeding of ensure 280 1/2 solution. Full strength ensure is available in 240 ml can. The PN should use how many ml of ensure to prepare feeding?
167 1000ml x 6 hour Xml 1 hour 1000/X 6/1 6X = 1000 X= 167 ml/hr
The HCP prescribes an IV infusion of 0.9% sodium chloride with 40 mEq KCI/500 ml to infuse over 3 hours for a client with hypokalemia. The PN should program the infusion pump to deliver how many ml/hr?
167 500ml 3hrs, Xml 1/hr 500/X, 3/1 500= 3X X= 166.66 or 167 ml/hr
A clients indwelling catheter is removed at 0930. The PN assesses the client every 2 hours for the desire to void. Which documented assessment is the earliest time to requiring further intervention by the PN?
1730 (5:30) unable to void
A client admitted to the unit from the ER receives a prescription for an IV infusion of 0.9% sodium chloride 1000 ml at 750 ml/4 hours. The IV administration set delivers 60 gtt/ml. The PN should program the infusion pump to deliver how many gtt/minute?
188 4 hrs = 240min 750ml x 60gtt = 45000/240 = 187.5 rounded up 188
A client receives a prescription for diltiazem (Cardizem) at 5mg/hr. The drug is dispensed as 125mg in 100 ml D5W. How many ml/hr should the PN program the infusion pump?
4 125/100= 1.25 Using the formula D/H X Q 5mg/1.25 mg X 1ml= 4 ml/hr
A client with impetigo receives a prescription for azithromycin (Zithromax ) 500 mg PO on day 1, then 250 mg/day on days 2-5 for total administration of 1.5 gram. The pharmacy has 250 mg tablets available. How many tablets total should the PN give to the client for the duration of treatment? Enter numeric value only
6 2 tablets day one 4 tablets on 2-5 2+4=6
A client is receiving acetaminophen (Tylenol) 0.65 g PO q 6 hrs for pain. Acetaminophen is available in 325 mg tablets. How many milligrams should the PN administer?
650 mg
A client who weighs 73 lbs is receiving phenobarbital PO. The PN refers to the published drug literature with recommends the dose of 2 mg/kg/dose. What dose in mg should the PN determine is recommended dose for this client?
66 mg 73/2.2 = 33.1122 33.1122 X 2mg = 66.2244 66mg
The PN receives four new admissions in an assisted living community. After reviewing the clients medical histories, which client should the PN evaluate for a higher caloric diet?
A client with bacterial pneumonia
The PN notifies the HCP that a male client has become combative and needs a protective device to prevent injury to self and others. Which principle should the PN use when selecting a protective device?
A protective device provides the least amount of immobilization
Following a cholecystectomy, a client asks the PN about dietary restrictions that may need to be followed. Which diet should the PN recommend?
A well balanced diet with no restrictions
After a large community disaster occurs, many seriously injured victims need to be hospitalized. Which client who is currently hospitalized should the PN most likely prepare for discharge?
A younger male adult with serum level INR of 2 who was admitted for DVT
A client with CKD begins to manifest Kussmaul respirations. What actions should the PN implement?
Administer prescribed sodium bicarbonate
The PN is caring for four clients. Which client's data requires further nursing action?
Adult with T2DM with fasting glucose levels at 190 mg for 3 days 70-110 normal range
A child with acute streptococcal pharyngitis is prescribed amoxicillin (Amoxil) suspension. The mother asks the PN when her child can return to school. Which information should the PN provide?
After child has taken antibiotics for 24 hours
The PN is reviewing preoperative instructions with a preschooler. Which technique should the PN use to most effectively promote the child's understanding?
Allow the child to manipulate some of the equipment to be used
A 9 y/o boy who had an emergency appendectomy during the night awakens and starts to cry when he does not see his parents at the bedside. He has an IV and a dressing covering the operative site. What action should the PN implement?
Ask the child to recall the surgical event and assess his pain level
A male client who receives albuterol nebulizing treatment PRN is asking the PN for his breathing treatment. Which assessment should the PN implement before administering the PRN prescription?
Breath sounds
A clients B/P is being monitored with an arterial catheter placed in the brachial artery. To prevent neuromuscular complications while the catheter is in place, what action should the PN implement?
Check pulses distal to the insertion site hourly
The PN is evaluating a client for an increased need of B12 after undergoing a subtotal gastrectomy. Which foods should the PN recommend that the client include in the diet?
Cheese, eggs, and fish
The PN is reinforcing dietary instructions to the parent of a 6 month old baby boy DX with PKU. Which foods should the PN direct the parents to eliminate in the infants diet?
Chicken and fish
A client with acute pancreatitis has a low serum calcium level. The PN observes that the lips, nose, and side of the face contract after the client's face is cleansed with a cloth. Which electronic documentation describes these findings?
Chvostek's sign noted
The PN is caring for an older client who is receiving oxygen 4l per nasal cannula. Which finding indicates a therapeutic response?
Client oriented to time and place
The PN is collecting data from clients electronic medical records for the nurse managers quality assurance review about documentation of client pain relief. What information should the PN include as the best measure of pain relief?
Client pain intensity documented 1 hour after analgesia
The PN is caring for a group of clients who are on a high protein diet. Which clients condition is most likely to experience the most therapeutic response with this diet?
Client recovering from illness or surgery
Based on these clients lab results, which client should be assigned to the PN?
Client with a serum calcium of 9.5 mg/dl Client with normal range levels
Which client information determines the best assignment for the PN?
Client with dependent edema is scheduled for discharge to home care No complex client
Which factors influence how the PN obtains vital signs on a client? Select all that apply
Clients height 5ft 6in, weight 240 lbs History of right radical mastectomy two years ago
Which client group is mostly to experience a therapeutic response from therapeutic touch?
Clients with headaches
The PN hears an auscultatory gap in the Korotkoff sounds of an older client with hypertension. What action should the PN implement when obtaining the clients B/P?
Continue to listen for the next Korotkoff's sound until the cuff is deflated
Which foods should the PN recommend for a client who is receiving chemo? Select all that apply
Cooked broccoli, cauliflower, boiled eggs Baked potatoes Pastas
The PN hears breath sounds that are short, popping and discontinuous on inspiration when auscultation a clients lungs. Which description should the PN document in the clients record?
Crackles auscultated
An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond? A. Review the importance of hygienic measures for improved health B. State that the healthcare provider has prescribed a bath today C. Offer the client several choices of times to bathe during the day D. Request that the client clarify his religious beliefs about bathing
D. Request that the client clarify his religious beliefs about bathing
A client who is three days postoperative complains of having "really bad pain" and wants medication now. What action should the PN implement?
Determine the location of pain
Which information related to a clients history of benign prostatic hypertrophy (BPH) should the PN report to the HCP?
Difficulty with urination Increased size of prostate gland cased by BPH compresses urethra
An older client who has been on bed rest is not eating well and is exhibiting abdominal distention, cramping, and is passing small amounts of liquid stool. Which prescribed action is most important for the PN to implement?
Digitally remove a fecal impaction
The PN is obtaining a blood specimen from a client's peripherally inserted central catheter (PICC). What action should the PN implement first?
Discard first 5ml of blood sample
The PN is changing the lochia stained sheets for a client who delivered a normal infant 2 hrs ago. What action should the PN take to change the linen?
Dispose lochia stained disposable peri pads and bed pans in biohazard boxes Place soiled sheets in a laundry hamper lined with plastic red bag Use clean gloves during contact with linen and disposable underpads
The PN performs a random blood glucose test for a client with a history of hypoglycemia and complains of dizziness. After the test, which action should the PN perform first?
Dispose of the lancet and test strip in proper receptacle
The PN is reinforcing the teaching to a pregnant client about her dietary needs. What amount of protein grams/ day should the PN recommend that the client add to her daily diet?
Divide pre-pregnancy weight by 2 equals protein needs
A client who is 8 hours postoperative begins using the incentive spirometer (IS) with 750ml inspiratory volume coughs up a large, thick light yellow white mucous plug. Which action should the PN take?
Document the findings SI stimulates coughing
A client who is postoperative is receiving an infusion at 80 ml/hr. At the end of 8 postoperative hours, the PN documents that the client tolerated 100 ml oral intake of ice chips, and urinate output is 1100 ml. What action should the PN take?
Document the intake and output findings
The PN is documenting the administration of a clients medication. Which entry by the PN complies with The Joint Commission (TJC) guidelines for use of abbreviations?
Dose of clonidine 0.15 mg given AC BID Trailing zeros""
The PN is checking the charge slips for a client who receives supplies from the units central supply area. Which charge should the PN validate on a daily basis?
Dressing supplies by the bedside
The PN is assisting the nurse with the care of a newborn immediately after deliver. What action should the PN perform?
Dry the infant and wrap in a warming blanket
The PN interview a client who had a total colectomy 2 weeks ago. The client claims to be confident in the management of the new colostomy, but is having problems with managing odor. What suggestions should the PN provide the client to help decrease odor in the colostomy bag?
Eat foods containing yogurt Drink a glass of buttermilk Eat sprigs of parsley
A client with a spinal cord injury is flushed and sweating profusely, complaining of a headache and nausea, and has elevated B/P with a slow pulse rate. What interventions should the PN implement first?
Elevate head of bed to a sitting position
An older adult female recently DX with CAD cooks at home using saturated fats. Which intervention should the PN implement to help the client reduce modifiable risk factors?
Encourage food preparation with various vegetable oils
Which intervention should the PN implement to help a client cope effectively with chronic pain?
Encourage using relaxation techniques
The PN is reinforcing the importance of increasing magnesium in the diet for a primigravida. The client asks why this is important? What information should the PN provide about magnesium needs during pregnancy?
Enhances the synthesis of proteins, nucleic acids and fats
Which technique is most important for the PN to implement when obtaining a specimen for urinalysis, culture, and sensitivity for a male client?
Ensure client understands to retract the foreskin and cleanse the meatus
Which intervention should the PN implement for a client who is scheduled for a lumbar puncture?
Ensure the clients bed is positioned flat
The PN is obtaining information for a male client's psychosocial assessment. Which action should the PN implement first?
Establish therapeutic relationship
A female client who is DX with T2D tells the PN that she hates to exercise and asks whether just following her 1000 cal diet will control her diabetes. Which response should the PN provide that offers the best information?
Exercise facilitates weight loss and decreases peripheral insulin resistance
A female visitor walks up to the PN in the hall and asks if the male client who she is visiting is going to recover from his illness. Which response should the PN provide?
Explain that client information cannot be shared
An older client who is unable to swallow is receiving continuous NGT feeding. Before administering medications through NGT, what action should the PN implement?
Flush the feeding tube with water
The PN is assessing a child who has a cast on the right lower leg. Which finding should the PN report to the charge nurse?
Foul odor from the cast's edge
Which action should the PN implement when administering an 8 oz can of concentration nutritional formula via clients GT?
Give 30ml of tap water after administering formula to flush tube
A client with delirium is confused and disoriented to time and place. He states he is experiencing visual illusions and tactile hallucinations. What actions in the place of care should the PN implement?
Give simple explanations about nursing care to be given Remove unnecessary furniture and equipment from the room Identify oneself each time the client is approached
The PN stops to help at a serious MVA and applies pressure to one of the victims neck that is spurting blood. The client subsequently dies. Which legal concept applies to the PN's actions?
Good Samaritan
The LVN is planning to attend an educational offering for continuing education units or contact hours. In order to qualify for CEUs, the LVN must recognize that the offering should include which essential element?
Has measurable outcome objectives
Which information is most important for the PN to obtain when preparing a client for ECT on a outpatient basis?
Have client maintain NPO status 8 hrs before ECT
A family member of a dying client asks the PN if the client knows the family is at the bedside. The PN explains that which of the five senses persist the longest during the dying process?
Hearing
A male Native American client with TB is visiting a HC clinic for follow up treatment. During the interview, the PN notices that the client keeps his eyes on the floor and does not make eye contact. How should the PN interpret the clients behavior?
His culture finds sustained eye contact rude or disrespectful
Rank the sequence of physiological changes that a newborn must initiate and adapt to extrauterine life after c-section delivery?
Initiation of respiration Maintain temperature Closure of fetal circulatory shunts Response of immune defense systems
A number of clients have arrived for care in a crowed ER. Which assignment should the PN accept?
Insert NGT for older adult client with abdominal distention
The PN is assisting the nurse with the care of a client with end stage emphysema who is on a mechanical ventilator. The PN auscultates decreased breath sounds in the right lung fields and notices that the client's neck veins are distended. Which additional assessment should the PN implement to report a tension pneumothorax to the nurse?
Inspect the trachea to see if its midline
When irrigating the external ear canals of an older adult client, which action should the PN use to soften dry cerulean for removal?
Instill mineral oil in the external auditory canal overnight before irrigation
The PN is visiting a client at home who asks if commercially prepared food products can age or spoil. Which foods should the PN explain have the likelihood of aging and creating a byproduct that is not healthy?
Jar of peanut butter
The PN is providing wound care for a newly admitted client with partial to full thickness burns to torso. Place the steps in the order of implication
Maintain room temperature above 76F Administer prescribed opioid analgesic Don gown, mask, and gloves Cleanse wounds with sterile NS Apply topical silver sulfadiazine (Silvadene)
The PN is checking the surgical dressing for a client who arrived on the postoperative unit one hour ago. The dressing has increased in the accumulation of serosanguinous drainage. What nursing action should the PN take?
Mark the outlined area of the drainage with date,time and initials
A client develops a vitamin K deficiency due to intestinal malabsorption. What intervention should the PN implement in the plan of care?
Monitor for signs of hematuria, melena, ecchymosis
The PN is caring for a school aged child with Reye's syndrome. What action is most important for the PN to implement?
Monitor intake and output
Which medication side effects should the PN tell the client to report to the HCP?
Multiple diarrhea stools begin after starting clindamycin (Cleocin)
What therapeutic response should the PN monitor for in a client who is taking medications for TB?
Negative sputum cultures and chest X-ray
Following a clients bladder surgery the PN notes that the ureteral catheter is no longer draining urine. What action should the PN take?
Notify HCP immediately
The PN is reviewing the medical record for a male client scheduled for an ECT and determines there is no signed consent form. What action should the PN take?
Notify HCP that the clients consent has not been signed
The PN is interviewing a client who has intermittent sheet pain while working in the garden. Which history should the PN obtain that predisposes this client to cardiovascular disease?
Obesity Diabetes Hypertension Hyperlipidemia Family history
Which intervention should the PN use to prevent obstruction of gastric feeding tube?
Obtain a prescription for a liquid drug form instead of crushing tablets
Which intervention is most important for the PN to implement for a client with heart failure?
Obtain daily weight
A male child who hit his face on the sidewalk after falling off his bike presents in the school nurses office with noticeable swelling around the mouth and nose and is carrying his front teeth in a tissue? Which action should the PN take first?
Obtain respiratory rate and effort
A client who is recently DX with bipolar disorder receives a new prescription for lithium. Which information should the PN reinforce to ensure the client's understanding?
Obtain serum lithium levels once a month
the PN finds an older female client lying on the floor. What action should the PN take first?
Obtain vital signs
A female client reports to the PN that she has had 10 watery diarrhea stools in the last 24 hrs and feeling dizzy. Which intervention should the PN implement first?
Obtain vital signs lying and standing
The PN is preparing to administer nasal drops into the ethmoid nasal sinus cavity. Which actions should the PN take?
Offer facial tissue to blot nasal secretions after instilling the drops Ask the client to remain supine for 5 minutes after instilling the drops Tilt the clients head backwards over the edge of the bed or pillow
Which action should the PN implement to minimize the risk of hypernatremia for an older client?
Offer fluids on a set schedule throughout the day
Which client receiving infusion therapy is the best assignment for the PN?
Older adult client who is confused and has a peripheral saline lock that should to be flushed every 8 hrs Assignments that should be aligned with PN scope of practice
The PN is completing the morning assessment for a client who is admitted with cellulitis of the right leg. Which finding about the client's lower extremities is most important for the PN to report immediately to the charge nurse?
Pale, cool too touch, diminished pulses
A client with T6 spinal cord injury who is implementing intermittent catheterization for bladder training suddenly complains of throbbing headache. The PN determines the clients b/p is elevated. What additional assessment should the PN implement?
Palpate the clients bladder for distention
Which pathophysiological findings are characteristics in children with cystic fibrosis? Select all that apply
Pancreatic enzyme deficiency Hypochloermia and hyponatremia Viscous respiratory secretions
Which early finding for a client with a new cast for a fractured leg should the PN report to the charge nurse?
Parenthesis of effected leg
The PN is administering a dissolved medication via NGT. After putting on gloves and attaching the irrigation syringe to the NGT, in which order should the PN implement the actions?
Pinch tubing to pour 15-30 ml tap water in the syringe barrel Release the tubing slowly to allow the solution to flow Observe the client for indications of intolerance during installation Add the medication solution after pinching the tubing
A client presents to the emergent care center reporting chest pain and feeling "lightheaded" as if he is "going to faint". What is the most important action the PN should implement?
Place client in a chair or upright on a stretcher
The HCP prescribes a cleansing enema for a adult prior to bowel surgery. Which interventions should the PN implement to ensure adequate bowel cleansing? Select all that apply
Place client on left side in Sims position Use enema fluid that is near 105F (40.5C)
A women who is 32 weeks gestation arrives at the prenatal clinic reports painless contraction and mucoid vaginal discharge. The fetal heart rate is 150 bpm. What action should the PN implement first?
Place in left lateral recumbent position
A client is pregnant arrives at urgent care clinic and complains of feeling very uncomfortable. The client states she feels a strong urge to have a bowel movement. Which action is most important for the PN to implement?
Place the client in a room with a precipitous delivery tray
An older client who reports having a dry mouth is having trouble swallowing pills. What action should the PN take when administering an enteric coated tablet?
Place the whole tablet in a spoonful of pudding
The PN is caring for a client who was recently DX with T2DM. What information is most important for the PN reinforce with a client about life style changes?
Portion controlled, heart healthy diet selection
The PN is assessing and obtains a pulse of 120 bpm respirations of 28 bmp and B/P of 80/60. Which action should the PN take first?
Position the client flat in the bed
The PN is caring for a client with angina pectoris. Which assessment finding is most important for the PN to report to the HCP?
Premature ventricular beats (PVCs) at 8 per minute
A male client is admitted to the hospital for placement of GT for enteral feedings and plans to return home where he lives alone. Which information is most important for the PN to provide to the client?
Preoperative instructions regarding the planned surgery
Which protocol regarding standard polices about prescriptions should the PN question?
Preoperative prescriptions should resume after a client Returns from surgery
At the beginning of the shift, the PN is reconciling a clients MAR, the prescriptions, and the dispensed drugs. Which available medication should be given?
Prescribe albuterol
A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. The client expresses fear about becoming addicted to these drugs. What information should the PN provide?
Prescribe opiates for cancer pain relief improve quality of life
A client with advanced cirrhosis is prescribed lactolose (Cephulac) 30ml QID. The client complains that the medicine is causing diarrhea. Which therapeutic response of the medication should the LVN provide the client?
Prevents constipation
A male client who had emergency bowel resection for a ruptured diverticulum 36 hrs ago is displaying increased restlessness, and his pulse rate is 110 bpm. He is exhibiting gross hand tremors and is plucking at the sheets and gown. During the next 48 hrs, it is most important for the PN to implement what nursing action?
Provide a safe environment
A client who has been taking furosemide (Lasix) for the past two months is 2 days postoperative for a super public prostatectomy. After breakfast, the client is in the bathroom straining to have a bowel movement when he calls the PN complaining of sudden onset SOB and acute chest pain. Which condition should the PN assess the client?
Pulmonary embolism
The PN is preparing to reinforce information with a client who has chronic pain. Which learning objective should the PN review?
Recalls 2 nonpharmacological interventions used to relieve pain
The PN is obtaining history from a client with acute glomerulonephritis. Which should the PN focus on disease etiology?
Recent Streptococcal infection
The PN obtains the assistance of an interpreter when caring for aprimiparousclient from Mexico who speaks very little English and delivered a full term neonate yesterday. When reinforcing the postpartum dietary plan of care for the client, what should the PN tell the interpreter to encourage the client to include in her diet?
Red meats Leafy green vegetables Fresh fruits
The HCP prescribes wrist restraints for an older male resident in a long term facility who is confused and has pulled out his urinary catheter twice. The PN assesses the clients radial pulses and skin condition under restraint every 2 hrs. Which additional measures should the PN implement?
Remove the restraints daily to reevaluate the clients needs Discontinue the restraints when the client is no longer at risk for self injury
A male client who is paraplegic due to diving accident is admitted to rehab unit. Which findings is most important for the PN to report to the interdisciplinary team?
Repeated refusal to see visitors
A male client with recurrent angina is receiving oxygen at 2 l/min and begins to complain that he feels "funny" in his chest. The telemetry monitor reveals a rapid narrow QRS complex at 170 bpm. Which action is most important for the PN to implement?
Report to charge nurse
A client who is 39 wks gestation arrives at the clinic and ask the PN if the client is ready to have her baby soon. Which finding should the PN respond to first?
Reports feeling wet and warm as if she is voiding involuntary
After undergoing exploratory laparotomy and bowel resection, a client with a NGT to suction complains of nausea and stomach distention. The PN irrigates the tube, but the irritating fluid dose not return. What action should the PN implement?
Reposition tube, and check for placement
Which acid based imbalance is a client with a history of severe COPD likely to develop?
Respiratory acidosis
The PN reviews the dietary treatment plan with a client who has ascites secondary to cirrhosis of the liver. Which information should the PN include when reviewing the dietary plan?
Restrict sodium intake
In which position should the PN place a client after the client has had a liver biopsy?
Right side lying
A client who delivered a normal baby 4 hrs ago has been unable to void. What nursing intervention should the PN implement first?
Rinse the perineum with warm water
A client arrives in the clinic complaining of radiating back pain. Which finding related to possible dissecting aneurysm should the PN report to the HCP.
Ripping chest pain and B/P 150/90 in right arm 120/70 in left arm
12 hrs after implantation of a cervical cesium implant, the PN finds the client crying. What action should the PN provide?
Stand a the foot of the bed and offer support for a few minutes
A client being discharged after repair of a retinal detachment. The PN reviews the written discharge info with the client and family. Which instruction should the PN emphasize to the client when arriving at home?
Take PRN antiemetic with early signs of nausea
The PN is administering eye drops to a client with glaucoma. Which technique should the PN implement to ensure the eyes drops are effectively absorbed topically?
Tell the client to move closed eyes from side to side
The PN is assisting the nurse in the administration of a unit of blood to a client with AB positive blood type. Which finding should the PN identify as a policy standard that should be addressed first?
The client dose not have an ID bracket
Which client outcome should the PN identify for a client with heart failure?
The client is able to dress and feed self without experiencing dyspnea
Which information should the PN reinforce for a client who has signed an informed consent for a surgery?
The expected benefits and outcomes of the procedure The nature of the therapy or procedure Potential risk of the procedure
A male client with acute pancreatitis has a NGT to suction. He asks the PN if he can have some sips of water or ice chips. Which rationale should the PN explain to the client about remaining NPO?
To minimize pancreatic secretions that cause pain
In the prescribed clinical pathway for an elderly client who is bedridden after the repair of a broken hip, transfer to the rehab unit should be implemented at 1 week postoperatively. Which intervention is most important for the PN to direct the UAP to implement to ensure the client can progress to this expected outcome?
Turn, cough, deep breathing ever 2 hours to prevent secretions pooling in the lungs
The PN is administering an optic medication to an adult client. In which direction should the PN pull the pinna during instillation?
Up and back
A client with bipolar disorder is being treated with cognitive therapy. Which actions should the PN implement to reinforce this treatment strategy?
Use affirmations and limit setting Report clients suicidal expressions to the therapist Encourage substituting negative thoughts for positive
Which measure should the PN implement as the most effective measure to help decrease clients cost?
Use filtered tap water instead of sterile water for jejunostomy tube feedings
Which information to improve nutrition status should the PN offer an older female client who lives alone?
Use herbs to spice up the flavor of the foods instead of extra salt Cook favorite foods in bulk and freeze in individual serving containers
The PN observes an UAP accidentally drop a vial of blood while placing it in the biohazard bag for transport to the lab. How should the PN direct the UAP to clean up the blood spill on the floor?
Use paper towels to absorb blood for disposal in biohazard container and treat floor with disinfectant
The PN is assisting a client with meal selection while in the hospital after MI. Which client choices indicate to the PN that the client understands a prescribed low fat, high fiber diet?
Vegetable soup, carrots,legumes, celery, toasted oat bread, and an apple
What is the first action the PN should take when assisting with the care of a healthy newborn immediately after birth?
Verify the establishment of respirations
When using non sterile procedure gloves, which action should the PN implement to ensure standard precautions are provided to all clients ?
Wash hands immediately after removing gloves
A client with gastroenteritis, nausea, and vomiting is currently on NPO status. The HCP prescribes oral intake to be advanced as tolerated. Which fluid should the PN offer first?
Water
A client with a possible mumps infection is admitted to an acute care facility. Which infection control precaution should the PN implement?
Wear a mask or respiratory within 3 feet of the client
An older client arrives at the outpatient clinic complaining of burning and severe right sided chest pain. The PN observes vesicular eruptions in a line across the anterior chest wall. What action should the PN implement?
Wear gloves when palpating
The PN is evaluating the clients knowledge of low sodium menu selections. Which food items listed by the client confirm appropriate choices? Select all that apply
White rice Steamed veggies Cottage cheese Tomatoes
The PN is caring for a child who is receiving chemo for leukemia. The child's granulocyte count is 250/mm3 and the platelet count is 20000/ mm3. Which intervention should the PN implement when performing oral hygiene?
Wipe teeth with moistened gauze sponges
During insertion of NGT into the right nares, the client starts to cough. Which action should the PN implement?
Withdraw the NGT to the oral pharynx, reposition clients head and reinsert
The PN is obtaining blood specimens for a client. After inserting the needle into the arm, the client screams and reports an electric "shooting" pain in the arm. What action should the PN implement?
Withdrawal the needle from the arm
When reviewing the need to take warfarin sodium ( Coumadin ) with a male client who is recently DX with chronic A fib, what explanation should the PN reinforce with the client?
prevents emboli
