Comprehensive exam 2 hesi
A female client who is waiting for the results of her breast biopsy tells the practical nurse (PN) that she fears it is cancer. How should the PN respond? A. "I understand how you feel." B. "I am sure everything will be fine." C. "This must be a difficult time for you." D. "They are finding new cures every day."
C. "This must be a difficult time for you." Rationale: The PN should acknowledge the client's feelings (C). Although this respond attempts to express empathy, unless the nurse has had the same experience, (A) may not be perceived as supportive. (B) offers false reassurance. (D) ignores the client's feeling and closes the topic
The practical nurse (PN) assigns care of a client who is HIV positive to a newly employed PN who states, I can't take care of that client. How should the PN respond? A. "I don't understand your response. Please explain what you mean." B. "Staff cannot pick and choose assignments based on a client's diagnosis." C. "This client will provide a learning opportunity for you, and I'm here to help." D. "I will give you a different client so you will be more comfortable."
A. "I don't understand your response. Please explain what you mean." Rationale: The ethical principle of beneficence guides decisions based on the clients well being or dignity. The PN should first assess the rationale supporting the response (A) which may include an infection such as a "Cold" that places the immunosuppressed client at risk
After reviewing discharge instructions with a male client who has hepatitis C, what statement by the client indicates to the practical nurse that the client understands his disease? A. "I will avoid taking any products with acetaminophen, such as Tylenol." B. "I will eliminate alcohol consumption until my infection subsides." C. "I should eat a diet rich in dark green leafy vegetables." D. "I understand that my other medications doses need to be increased."
A. "I will avoid taking any products with acetaminophen, such as Tylenol." Rationale: Tylenol is metabolized in the liver and should be avoided with clients with liver disease
The practical nurse (PN) is participating in a group interview of an applicant who will work in the clinic as a staff PN. Which question is best to ask the applicant? A. "This position requires working on-call every fourth weekend. Can you do that?" B. "Do you have child care arrangements for your children?" C. "Do you have any religious requirements that need scheduling accommodation?" D. "Are you going to be the sole supporter for your family?"
A. "This position requires working on-call every fourth weekend. Can you do that?" Rationale: Job interview questions must be specifically job related (A)
Which individual should the practical nurse (PN) respond to first? A. A visitor is lying still on the floor in the middle of the unit hallway. B. The nursing supervisor is waiting to talk with the PN on the phone. C. An unlicensed assistive personnel who reports a sink is leaking water on the floor. D. A postoperative client who is requesting medication for pain that is 10 (0-10 scale).
A. A visitor is lying still on the floor in the middle of the unit hallway. Rationale: The visitor who is unresponsive on the floor (A) requires immediate attention to determine if resuscitation is indicated. (B) can be contacted after the emergency situation is addressed. (C) can be delegated to the UAP to clean up the water spill and notify maintenance and housekeeping personnel. (D) can be addressed after the emergency or by another nursing team member.
A woman who is 32-weeks gestation arrives at the prenatal clinic and reports painless contractions and mucoid vaginal discharge. The fetal heart rate is 150 beats/minutes. What action should the practical nurse (PN) implement first? A. Place in the left lateral recumbent position. B. Ask about recent sexual intercourse. C. Encourage an increase in oral fluid intake. D. Determine when the contractions began.
A. Place in the left lateral recumbent position. Rationale: Preterm labors symptoms include contractions and mucoid vaginal discharge so the PN should place the client in the left lateral position
A client with chronic kidney disease (CKD) begins to manifest Kussmaul respirations. What action should the practical nurse implement? A. Administer prescribed sodium bicarbonate. B. Restrict sodium and fluid intake. C. Provide additional potassium rich foods. D. Give prescribed sevelamer (Renagel).
A. Administer prescribed sodium bicarbonate. Rationale: Kussmaul breathing occurs in an effort to compensate for metabolic acidosis, which results from kidneys inability to excrete acid products such as ammonia, which is normally buffered by bicarbonate. To help correct this imbalance, supplements such as sodium bicarbonate (A) are prescribed and should be administered promptly. Although (B) is indicated in CKD, this does not address the client's onset of signs of metabolic acidosis. (C) is not recommended due to the kidneys inability to excrete potassium. Renagel (D) is a phosphate binder that reduces phosphate absorption and elevated serum levels that occur with kidney failure.
The practical nurse (PN) is caring for four clients. Which client's data requires further nursing action? A. An adult with type 2 diabetes mellitus (DM) who has fasting glucose levels at 190 mg for 3 days. B. An older adult with head injury who has sequential hourly Glasgow Coma Scale (GCS) scores of 13, 14, and 15. C. An adolescent with pneumonia who has white blood cell count of 10,000/mm3 2 days after receiving antibiotics. D. An adult with a pulse of 110 and blood pressure of 150/80 following a lumbar puncture.
A. An adult with type 2 diabetes mellitus (DM) who has fasting glucose levels at 190 mg for 3 days. RATIONALE: The client with DM (A) who has fasting glucose levels of 190 mg for 3 days needs further action for the uncontrolled serum glucose. (B) is improving with a final GCS of 15, which is normal. (C) is improving since the white blood cell count is within normal. (D) may be related to anxiety after a lumbar puncture procedure, continued monitoring is indicated.
A newborn with apnea is being discharged from the hospital with home monitoring. What information concerning the infant's care should the practical nurse review with the parents? A. Cardiopulmonary resuscitation (CPR). B. Administration of intravenous antibiotics. C. Reassurance that the infant cannot be electrocuted during monitoring. D. Advise that the infant not be left with caretakers, such as babysitters.
A. Cardiopulmonary resuscitation (CPR). Rationale: Apnea of infancy (AOI) engenders great anxiety in parents, and the initiation of home monitoring presents additional emotional stress. When home monitoring is required the parents should receive instructions that include cardiopulmonary resuscitation(A). (B) does not indicate Apnea
A client who sustained a C4 injury in a head-on automobile collision is admitted to the neurological unit. Which priority assessment should the practical nurse (PN) monitor? A. Depth of respirations. B. Neuro focused checks. C. Pedal pulses. D. Blood pressure.
A. Depth of respirations. Rationale: The cervical plexus (first 4 cervical nerves) includes the phrenic nerve which innervates the diaphragm, so a C-4 cord injury can cause respiratory distress, which requires close monitoring of respiratory depth (A) to monitor the adequacy of oxygenation, the priority. Breathing is the priority over neurological checks (B), pedal pulses (C), and blood pressure (D).
The practical nurse (PN) is assisting the nurse with the care of a newborn immediately after delivery. Which action should the PN perform first? A. Dry the infant and wrap in a warming blanket. B. Stimulate respirations by rubbing the newborn's back. C. Evaluate skin color, heart rate, and muscle tone. D. Give supplemental oxygen using blow-by technique.
A. Dry the infant and wrap in a warming blanket Rationale: After delivery, the newborn's mouth and nose should be suctioned with a bulb syringe to clear the airway and prevent aspiration. To prevent cold stress, the newborn should be dried and and wrapped in warm blanket (A). After evaluation (C), (B and D) should be provided if indicated.
Which information should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP) who is newly assigned to the unit? A. Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. B. Determine if pain subsides 20 minutes after a client receives an injection. C. Report signs of infection in urine that collects in a bedside drainage unit. D. Observe how clients are using an incentive spirometer after surgery.
A. Keep head-of-bed elevated 45 degrees for clients with an infusing enteral pump. Rationale: Information about the basic care clients such as positioning (A) should be specific to a common intervention or treatment and should focus on task within the scope of the UAP's assignment
A child is admitted for severe abdominal pain and possible appendicitis. Laboratory and x-ray studies are prescribed. During the diagnostic period, the practical nurse should implement which nursing actions? (Check all that apply.) A. Maintain child's comfort. B. Relieve parent and child's anxiety. C. Prepare for surgery. D. Give oral home medications. E. Encourage ambulation.
A. Maintain child's comfort. B. Relieve parent and child's anxiety. C. Prepare for surgery.
An infant receives an Apgar score of 9 at one minute following birth. Which deduction in the total score, based on the Apgar scoring system, generally results in a normal, healthy neonate receiving an Apgar score of 9 instead of 10? A. Pink body with bluish discoloration of hands and feet. B. Heart rate greater than 100 beats/minute. C. Grimace and cough or sneeze. D. Some flexing of arms and legs.
A. Pink body with bluish discoloration of hands and feet. Rationale: The Apgar score is determined by evaluating the newborn infant's appearance (color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respirations. A score of 10 is highly unusual, and most newborns lose a point for the bluish coloring to their hands and feet, which will normalize to a pink coloring once their body temperatures have warmed up sufficiently (A). The findings described for heart rate (B), reflex irritability (C), and muscle tone (D) result in the infant receiving the maximum score of 2 points for each, with no point deductions made
Which finding in a 4-month-old infant warrants further investigation by the practical nurse? A. Wets 8 diapers a day. B. Grunts with expiration. C. Protruding abdomen. D. Inability to sit up without support.
B. Grunts with expiration. Rationale: Grunting on expiration (B) is a sign of respiratory distress and requires immediate attention. (A, C, and D) are normal findings for a 4-month-old.
A client who is pregnant arrives at an 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 practical nurse (PN) to implement? A. Place the client in a room with a precipitous delivery tray. B. Collect a urine specimen using a clean catch container. C. Ask the client if she knows her expected date of delivery. D. Inspect the perineum for the presence of a bloody show.
A. Place the client in a room with a precipitous delivery tray. Rationale: The client is manifesting signs of an imminent delivery, which includes regular contractions that are very uncomfortable, a strong urge to defecate, and pushing, so she should be immediately placed in the room with a precipitous delivery tray (A) to ensure a safe, sterile environment for delivery. (B, C, and D) can be implemented after the client is prepared for possible precipitous delivery.
When reviewing the safety precautions regarding newborns, what information should the practical nurse communicate to the parents? A. Position the infant to sleep on the baby's back. B. Use a crib with slats no more than 4 inches apart. C. Propping a bottle can be done when the infant gets older. D. Place the infant a front-facing car seat in the automobile.
A. Position the infant to sleep on the baby's back. Rationale: The incident of sudden infant death syndrome (SIDS) decline when infants are positioned on their backs (A), instead of prone for sleeping. Crib slats (B) 2.375 inches apart to prevent the baby from slipping. (C) Never prop a babies bottle. (D)Infant who weighs less than 30lbs should be placed in a rear facing car seat.
A 14-year-old female arrives in the school nurse's office seeking information about healthcare agencies in the community. The practical nurse (PN) understands the client can make an autonomous healthcare decision if she has which circumstance? A. Pregnancy. B. Funds to pay for her own care. C. Homelessness. D. A life-threatening condition.
A. Pregnancy. Rationale: According to the supreme court a minor who is pregnant (A) can make an autonomous healthcare decision
The practical nurse (PN) is caring for a client with angina pectoris. Which assessment finding is most important for the PN to report to the health care provider? A. Premature ventricular beats (PVC) at 8 per minute. B. Chest pain subsides when the client returns to bed. C. Sinus tachycardia at 120 beats/minute. D. Oxygen flow rate at 4 liters/minute.
A. Premature ventricular beats (PVC) at 8 per minute. Rationale: Excessive and multi-focal PVCs (A) are ineffective beats originating from various foci in the myocardium that are a precursor for dysrhythmia progression to ventricular tachycardia or ventricular fibrillation. (B, C, and D) are important, but the client's increased myocardial irritability increases the client's risk a life threatening dysrhythmia and should be reported immediately
When reviewing the need to take warfarin sodium (Coumadin) with a male client who is recently diagnosed with chronic atrial fibrillation, what explanation should the practical nurse reinforce with the client? A. Prevent emboli. B. Stop plaque buildup. C. Dissolve blood clots. D. Control heart rhythm.
A. Prevent emboli. Rationale: Atrial fibrillation is a condition in which the upper two chambers of the heart beat irregularly with the lower two chambers, which is a chaotic rhythm that causes the blood to pool and clot, which leads to stroke. Coumadin helps to prevent the formation of emboli (A) by blocking the action of vitamin K in the liver and reducing the amount of clotting factors in the blood. Coumadin does not stop the buildup of plaque (B), dissolve existing blood clots (C), or control the rhythm of the heart (D).
Which action should the practical nurse perform first for a child who is injured on the school grounds and has an obvious mis-alignment of the lower forearm? A. Remove the child's finger rings. B. Assess and document the child's level of pain. C. Evaluate the child's range of motion. D. Place arm in a sling at level of the child's heart.
A. Remove the child's finger rings. Rationale: The child is a risk for swelling in the distal areas of the affected arm and hand. Removal of finger rings (A) should be implemented first to remove any potential constriction that may occur after tissue injury or fracture of the lower arm
A male client with recurrent angina is receiving oxygen at 2 liters/minute and begins to complain that he feels funny in his chest. The telemetry monitor reveals a rapid narrow QRS complex at 170 beats/minute. Which action is most important for the practical nurse to implement? A. Report the findings to the charge nurse. B. Tell the client to remain on bedrest. C. Obtain the client's pulse oximetry reading. D. Call the rapid response team.
A. Report the findings to the charge nurse. Rationale: The client is likely experiencing supraventricular tachycardia (SVT), which should be reported to the charge nurse (A) and healthcare provider for immediate treatment. Bedrest (B) minimizes myocardial demand for oxygen, but rest does not change the rate of SVT. (C) may be indicated, but the first action is to report the findings. (D) is indicated if the client's rhythm progresses to ventricular tachycardia (VT) or ventricular fibrillation
Which directions should the practical nurse (PN) provide to an unlicensed assistive personnel (UAP)? A. Report the total urine output for the client on intake and output. B. Offer the client 6 grams of carbohydrates during each meal. C. Obtain the vital signs for the client who is returning from surgery. D. Observe and report any signs of infection in the client's urine.
A. Report the total urine output for the client on intake and output. Rationale: Directions should be given to the UAP that are clear and precise about basic client care, such as the collection of data related to intake and output (A). (B) requires nursing judgment of the licensed nurse. (C and D) are client assessment, which is a component of the nursing process and the responsibility of the licensed nurse.
A client arrives in the clinic complaining of radiating back pain. Which finding related to a possible dissecting aneurysm should the practical nurse (PN) report to the healthcare provider? A. Ripping chest pain and blood pressures of 150/90 in right arm and 120/70 in left arm. B. Sudden right flank pain with gross hematuria. C. Sharp epigastric pain that radiates to the scapula. D. Lower back pain that radiates down back of the leg and is more intense with coughing.
A. Ripping chest pain and blood pressures of 150/90 in right arm and 120/70 in left arm. Rationale: A dissecting aneurysm is a tearing of the intima of a major artery, such as the ascending aorta, and classically presents with the onset of sudden, severe, ripping pain that moves. Depending on the location, as the intima of the artery tears, a difference in the extremity perfusion (A), deceased urine output, or petechiae on the feet occur. (B) is characteristic of a kidney stone (renal lithiasis). (C) occurs with acute biliary colic and cholelithiasis. (D) describes pain associated with an intervertebral disc herniation
A female client recently diagnosed with colon cancer is admitted for surgery. When the practical nurse (PN) asks the woman how she is feeling, the client starts to cry. How should the PN respond? A. Sit in silence with the client as she cries. B. Leave her alone to provide privacy. C. Remind her that early surgery can be a cure. D. Ask a chaplain to come see the client.
A. Sit in silence with the client as she cries. Rationale: Sitting down with the client in silence (A) is an effective form of therapeutic communication that allows the client to express herself with tears. Since the client has not asked to be left alone, (B) may be interpreted as abandonment. The client should be allowed to grieve without false reassurance (C). (D) should be implemented in response to a client's request.
A healthcare provider begins screaming at the practical nurse (PN) who is standing at the nurses' station and demands that the laboratory results be made available immediately. Which action should the PN take first? A. Suggest moving to a private area to discuss further. B. Complete an incident report about unprofessional behaviors. C. Request that the laboratory send the reports immediately. D. Call the nursing supervisor to intervene in the situation.
A. Suggest moving to a private area to discuss further. Rationale: Moving to a private area to discuss the issues away from public display is the first action (A), which may help de-escalate the situation. (B) may be indicated after the nursing supervisor is called to assist with resolving the incident. Although (C) is indicated, a setting that provides privacy should be used first to minimizing further disruptive interaction. The nursing supervisor (D) should be called to assist with the situation but privacy for further discussion should be suggested first
An older male client with a history of hypertension presents in the urgent care center with an elevated blood pressure and tachycardia. Which finding should the practical nurse report to the healthcare provider immediately? A. Tearing pain that has moved to his low back. B. Sharp sensation with deep breath. C. Pain elicited upon palpation. D. Pain level at 10 (0-10 scale).
A. Tearing pain that has moved to his low back. Rationale: The client has classic findings, such as age and history of hypertension, for a possible dissecting aneurysm. Severe tearing pain that moves from the client's chest to the back (A) is symptomatic of this life threatening and requires immediate treatment and must be reported immediately. (B and C) are not consistent with a dissecting aneurysm. Since other benign conditions can cause severe pain, the severity of the pain (D), in and of itself, is not the most important finding.
An older client who takes digoxin (Lanoxin) daily calls the clinic about not feeling well. The new onset of which finding should the practical nurse advise the client to come for a visit with the healthcare provider? A. Vomiting. B. Tachycardia. C. Constipation. D. Tinnitus.
A. Vomiting. Rationale: In older clients, nausea and vomiting (A) are early signs of digoxin toxicity, which can occur due to cumulative effects, even with subtoxic digoxin levels. Bradycardia, not tachycardia (B) is a sign of digoxin toxicity. Constipation (C) is not related to digoxin toxicity. Tinnitus (D) is a symptom of aspirin toxicity.
After a large scale community disaster occurs, many seriously injured victims need to be hospitalized. Which client who is currently hospitalized should the practical nurse most likely prepare for discharge? A. An older male who was admitted with heart failure (HF) and a troponin level of 3 ng/ml. B. A young adult male with a serum INR of 2 who was admitted for deep vein thrombosis. C. An older female client who is admitted after experiencing numbness of the left side of face. D. An adult female with acute abdominal pain who has a hemoglobin of 10 grams/dl.
B. A young adult male with a serum INR of 2 who was admitted for deep vein thrombosis. Rationale: The client with a deep vein thrombosis has an INR value that indicates a therapeutic response (B) to treatment and should be ready for discharge. Elevated troponin level (A) is diagnostic of an acute myocardial infarction. Unilateral facial numbness may indicate the client is experiencing an acute brain attack (stroke) (C). (D) may require emergency surgical intervention.
Which client should the practical nurse (PN) obtain a Glasgow Coma Scale (GCS) score? A. A female client with Alzheimer's disease. B. An adolescent male who hit his head due to alcohol toxicity. C. A male client who is chemically paralyzed and intubated. D. A young adult female with bipolar disorder.
B. An adolescent male who hit his head due to alcohol toxicity. Rationale: The GCS score evaluates a client's neurological responses after experiencing an acute head injury. Although alcohol toxicity may alter the adolescent's responses, the GCS score should be implemented during and after alcohol detoxification to screen for neurological changes characteristic of a head injury (B). (A, C, and D) do not experience changes in spontaneity of eye opening, best verbal response, and best motor response consistent with a head injury
A male client who receives albuterol (Ventolin) nebulizing treatment PRN is asking the practical nurse (PN) for his breathing treatment. Which assessment should the PN implement before administering the PRN prescription? A. Incentive spirometer level. B. Breath sounds. C. Respiratory rate. D. Accessory respiratory muscles effort.
B. Breath sounds. Rationale: Albuterol (Ventolin), a bronchodilator, is indicated for wheezing caused by narrowing of the air passages, so the client's breath sounds (B) should be auscultated to determine if the albuterol breathing treatment is indicated. Incentive spirometer (A) is an inspiratory exercise used to inflate alveoli and prevent atelectasis, not treat reactive airway disease. (C and D) do not provide accurate information about bronchial airway patency
A client with "fever of undetermined origin" awakens with right periorbital swelling. Which action should the practical nurse take first? A. Apply warm moist compress to the right eye. B. Check for conjunctival erythemia and drainage. C. Determine if the client has nasal congestion. D. Ask the client about history of drug reactions.
B. Check for conjunctival erythemia and drainage. Rationale: Unilateral periorbital swelling is most likely a local infection, so the PN should assess the client for additional findings of eye infection, such as conjunctival erythemia and drainage (B) from the eye. The findings should be reported to the charge nurse for additional actions before (A) is implemented. Although (C and D) may provide additional information related to the client's swollen eye, a focused assessment of the eye should be completed first
A group of practical nurses (PNs) who work on a medical-surgical unit believe they are understaffed. Which data should the PNs consider when preparing the justification for additional staff? A. Staffing ratios in other states. B. Client acuity and census. C. Overtime payment and unfilled positions. D. Number and frequency of client complaints.
B. Client acuity and census. Rationale: When presenting the need for increased staff, the PNs should present the request using staffing guidelines that consider client acuity, number of clients, and length of stay(B).
What action is most important for the practical nurse (PN) implement to help control pain for a client who is two days post-laminectomy? A. Encourage the client to request pain medication. B. Determine the client's pain level at regular intervals. C. Evaluate the client's pain level after administering an analgesic. D. Instruct the client to use relaxation techniques to control the pain.
B. Determine the client's pain level at regular intervals. Rationale: Pain control is best managed by assessing the client's pain level and character on a regular basis (B). (A, C and D) should be implemented but do not provide consistent pain management as the implementation of regular assessment and analgesic administration
Which medication side effects should the practical nurse tell the client to report to the healthcare provider? A. Constipation occurs when taking hydrocodone/acetaminophen (Vicodin). B. Multiple diarrhea stools begins after starting Clindamycin (Cleocin). C. A weight loss of more than 5 pounds is identified with exenatide (Byetta). D. A headache occurs after taking the morning dose of nitroglycerin (Nitro-Dur).
B. Multiple diarrhea stools begins after starting Clindamycin (Cleocin). Rationale: Severe diarrhea is an indication of pseudomembranous colitis that can result from taking Clindamycin, and the client should promptly report this side effect to the healthcare provider (B). Vicodin, a narcotic analgesic, slows peristalsis and causes constipation (A), which is a common side effect managed with increased dietary intake of bulk, fluids, and ambulation. Byetta is known to cause transient nausea, feeling full, and weight loss (C). Up to 50% of all clients experience mild to severe transient headaches after taking nitroglycerin (D) related to the vasodilation
A client who had a total knee arthroplasty (TKA) three days ago is being transferred to the rehabilitation center. The healthcare provider prescribes activity as tolerated. Which action should the practical nurse (PN) take? A. Ask someone to follow the client with a wheelchair. B. Obtain clarification of prescription about weight bearing. C. Inquire about routine physical therapy progression. D. Ask the client what he did yesterday for activity.
B. Obtain clarification of prescription about weight bearing. Rationale: The healthcare provider should indicate the amount of weight bearing the client should safely be able to tolerate after TKA, so the PN should clarify the prescription (B). (A) is a safety measure to prevent falls while the client begins mobilization. (C) may be helpful but does not provide individualized care for the client. (D) provides a comparison for the client's progression with activity as tolerated
Which intervention is most important for the practical nurse to implement for a client with heart failure (HF)? A. Maintain a record of intake and output. B. Obtain daily weights. C. Provide a salt substitute. D. Monitor a client's diary of daily exercise tolerance.
B. Obtain daily weights. Rationale: In heart failure, the inefficient pumping action of the heart causes fluid retention that is best evaluated by an increase in body weight. Obtaining daily weights (B) is the most important action in monitoring a client with HF. Although a record of intake and output (A) provides a tool of monitoring fluid load, the most accurate assessment of fluid retention is daily weight. Salt restriction, no substitution (C) should be included in the care of the client with HF. Although daily exercise tolerance (D) reflects cardiac workload, an increased fluid load is best gauged by weight.
A male child who hit his face on the sidewalk after falling off his bike presents in the school nurse's office with noticeable swelling around the mouth and nose and is carrying his front teeth in a tissue. Which action should the practical nurse (PN) take first? A. Call the parent for permission to treat. B. Obtain the respiratory rate and effort. C. Place the teeth in a cup of sterile water. D. Assess the level of pain and apply ice.
B. Obtain the respiratory rate and effort. Rationale: Adequacy of breathing (B) is always an initial priority, especially with facial trauma and swelling (B), which could cause aspiration of a tooth. (A, C, and D) should be implemented after ensuring the child airway is open and his breathing is stable
A child who is currently undergoing chemotherapy (CT) for leukemia is brought to the clinic for a possible broken ankle. What priority action should the practical nurse implement? A. Obtain a current white blood cell (WBC) count. B. Place a mask on the child. C. Take the child's temperature and pulse. D. Apply ice and elevate the ankle.
B. Place a mask on the child. Rationale: The child who is receiving CT for leukemia is immunosuppressed and should be protected from airborne pathogens and other sick children in the clinic. Placing a mask on the child (B) provides transmission-based precautions that reduces the risk of the child to pathogens by droplet and takes priority over the WBC count (A), vital signs (C), or first aid treatment to the ankle (D).
The practical nurse (PN) is using bag-mask device to administer artificial ventilation for a three-year-old child. Which method is best to use to create a seal while holding the mask in place? A. Perform a head-tilt, chin-lift maneuver when spinal trauma is suspected. B. Place the mask over nose and mouth using a c-e one-hand technique. C. Measure the mask size from the supraorbital rim to the mandible tip. D. Position a rolled-up towel under the head to aid positioning of the airway.
B. Place the mask over nose and mouth using a c-e one-hand technique. Rationale: When using one hand to secure the mask snugly against the skin, the rescuer should place the thumb and first finger on top of the mask to create a "c" and place the 3 other fingers (the "e") underneath the chin (B). The jaw thrust maneuver, not (A), should be used when spinal trauma is suspected. The mask should be measured from the bridge of the nose to the chin, not (C) which applies pressure on the eyeballs. (D) causes hyperflexion of the neck, which closes the airway
The practical nurse (PN) is caring for a newborn with a bluish discoloration of the hands and feet. What action should the PN implement? A. Complete an incident report. B. Record the finding on the medical record. C. Obtain axillary temperature. D. Administer blow-by oxygen to the newborn.
B. Record the finding on the medical record. Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal variation of circulatory instability in the newborn. The finding should be documented (B). (A and D) are not indicated. Although monitoring the axillary temperature may be implemented, acrocyanosis does not indicate cold stress
A male client's signed advance directive indicates that he wants no resuscitation measures, but the family disagrees and asks the practical nurse (PN) to try to change the client's mind regarding the decision. What action should the PN take? A. Obtain client's permission to talk about the details of the document. B. Refer the family to the charge nurse to facilitate family discussion. C. Report the issue to the healthcare provider. D. Ask a pastoral care advisor to talk to the family.
B. Refer the family to the charge nurse to facilitate family discussion. Rationale: In cases where a disagreement exists, every effort should be made to help the client and family resolve the issue. The PN should refer the family to the charge nurse who can facilitate the discussion or explain the client's self-determination rights. (A) is not necessary. Although the healthcare provider should understand the family issues (C), some attempt to remediate the conflict should be implemented by the charge nurse. Asking a pastoral care advisor to talk to the family (D) may help, but the family should be consulted first to find out if they want outside assistance
The practical nurse (PN) is caring for a client who had a total hip replacement yesterday. Which task should the PN assign to an unlicensed assistive personnel (UAP)? A. Turn the client from side to side every two hours. B. Remind the client to use the incentive spirometer. C. Position the client in a sitting position for breakfast. D. Assist the client in the use of a bedside commode.
B. Remind the client to use the incentive spirometer. Rationale: Reminding a client to use the incentive spirometer (B) can be assigned to the UAP, and the client's ability to effectively use IS should be evaluated by the PN. An abductor pillow is required during turning and this precautions must be included in the assignment (A). (C and D) should not be implemented on the first postoperative day for a client with a new hip replacement
A client who is 39-weeks gestation arrives at the clinic asks the practical nurse if she is ready to have her baby soon. Which finding should the practical nurse (PN) respond to first? A. Continues to experience morning nausea and hiccups. B. Reports feeling wet and warm as if she is voiding involuntarily. C. Experiences abdominal contractions that occur every day. D. States that breathing is easier since the fundus height dropped.
B. Reports feeling wet and warm as if she is voiding involuntarily. Rationale: Rupture of the membranes that may leak at first and is often reported as a sensation of perineal wetness (B), so the PN should assess first the client for early sign of labor. (A, B, and D) are common findings in the last trimester that do not indicate the onset of true labor.
A client with type 2 diabetes mellitus is admitted to the hospital for an exacerbation of asthma. The practical nurse (PN) administers hydrocortisone (Solu-Cortef) 60 mg PO every 6 hours. What information should the PN to review the next day? A. Serum potassium. B. Serum glucose. C. Respiratory rate. D. Blood pressure.
B. Serum glucose. Rationale: High doses of glucocorticoidsteriods can cause an elevation in the serum glucose level, so the PN should review the clients serum glucose(B)
The practical nurse (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? A. The drainage is brown liquid. B. Skin maceration around stoma. C. The stoma bleeds when touched. D. Foul odor noted when bag removed.
B. Skin maceration around stoma. Rationale: Maceration around the stoma (B) may indicate that the ileostomy bag is leaking and the peristomal skin is irritated by liquid stool from the ileum. (A and D) are expected findings. (C) should be monitored, but peristomal skin destruction is painful and affects the client's recovery
The practical nurse (PN) observes a family member accidentally stumble over the three-compartment drainage system (Pleur-evac®) for a client with a chest tube to suction. The PN sees that the drainage system container is cracked and the chest tube is disconnected. What action should the PN implement? A. Cover the end of the chest tube with a sterile gloved hand. B. Submerge the end of the chest tube in a bottle of sterile water. C. Fill the water-seal chamber in the chest drainage container. D. Cover chest tube site with petroleum-based impregnated gauze.
B. Submerge the end of the chest tube in a bottle of sterile water Rationale: The disconnected chest tube allows air into the chest cavity, which causes pneumothorax. The water seal should be reestablished by quickly placing the end of the tube in a bottle of sterile water (B) until a new apparatus can be prepared. A gloved hand (A) cannot create a sufficient seal against air entering the pleural space. (C) is not indicated. (D) is indicated if the chest tube dislodges from the chest, not the drainage system container
The practical nurse (PN) is assigned to assist with receiving clients in the Emergency Department (ED) following a community disaster. Which client finding should the PN recognize as the highest priority for care? A. Fractured femur and the client cannot move either leg. B. Sucking chest wound with protruding glass shard in chest. C. Full-thickness burns over 50% of the client's body. D. A woman with vaginal spotting who is 16-weeks gestation.
B. Sucking chest wound with protruding glass shard in chest Rationale: In any disaster, an immediate threat to life is the priority. The highest priority client is oxygenation, so the client with a sucking chest wound should receive immediate care. The care of the other clients (A, C, and D) should be imminently given, but do not have the priority of (B).
A client is being discharged after repair of a retinal detachment. The practical nurse (PN) reviews the written discharge information with the client and family. Which instruction should the PN emphasize to the client when arriving at home? A. Limit reading or writing for 3 weeks. B. Take a PRN antiemetic with early signs of nausea. C. Keep the head flat and centered when lying down. D. Self administer eye medications.
B. Take a PRN antiemetic with early signs of nausea. Rationale: To minimize increased intraocular pressure, it is most important that the client take an antiemetic as soon as nausea is experienced (B) to prevent vomiting that can cause displacement of the retinal repair
The practical nurse (PN) assigns the task of obtaining vital signs for all the clients on a 24-bed unit to an experienced unlicensed assistive personnel (UAP). What action should the PN take to ensure the clients are receiving safe care? A. Review vital signs trends of each client at end of shift. B. Take vital signs for any client with abnormal findings. C. Tell the UAP to report any abnormal vital signs. D. Accompany the UAP while obtaining vital signs.
B. Take vital signs for any client with abnormal findings. Rationale: To ensure safe care, the PN should take the vital signs for any client with abnormal results to evaluate the client's condition (B). Trends should be evaluated on an ongoing basis, not just at the end of the shift (A). Although (C) should be implement, specific information and parameters for abnormal findings should be included in the assignment to the UAP. Obtaining vital signs is within the scope of the UAPs assignment, so (D) is not necessary
The practical nurse (PN) is visiting an older male client in his home. Which observation requires intervention by the PN? A. The household pet wears a bell. B. There are piles of papers laying on the floor. C. The curtains are drawn shut during the day. D. The staircase is carpeted.
B. There are piles of papers laying on the floor. Rationale: Papers cluttering the floor increases the client's risk for falls (B), so the PN should address common home safety measures with the client. (A) is a good technique to help the client recognize if the pet is near or in the path that the client is walking. While (C) may be a client preference, it is not a safety concern if there is adequate indoor lighting. Throw rugs are a concern, but (C) should not present a safety hazard.
A client in a nursing home becomes violent and verbally threatens an unlicensed assistive personnel (UAP). Which is the best way for the practical nurse (PN) in charge during the shift to handle the staff's reaction to the incident? A. Encourage UAP to deal with it privately to prevent compromising client confidentiality. B. Offer a group discussion session so staff can share their thoughts and feelings. C. Invite staff out after hours to help distract them from the disturbing client event. D. Refer the UAP to human resources department for a counseling session with a therapist.
B.Offer a group discussion session so staff can share their thoughts and feelings Rationale: A critical incident stress debriefing evolves expression of personal feelings, discussion, and working on unresolved emotional issues to minimize post traumatic stress for the staff member. A CISD is the best action for the PN in charge to take (B) in conjunction with the guidance and assistance of the nursing supervisor in the facility
After a community disaster, two clients must be placed in the same room. Which client should the practical nurse select for placement in a room with a client with systemic lupus erythematosus (SLE)? A. An 80-year-old client with diabetes mellitus and pneumonia. B. A client with a productive cough with yellow phlegm. C. A client scheduled for an emergency appendectomy. D. A 20-year-old with the diagnoses of Neisseria meningitis.
C. A client scheduled for an emergency appendectomy. Rationale: A client with SLE is immunosuppressed and is susceptible to infections, so the client with appendicitis (C), which is an intra-abdominal inflammation of the appendix, is the best option to place in the same room. A client with an infectious or contagious disease (A, B, and D) should not be in the same room with a client with SLE.
Which client who arrives at the urgent care clinic should be seen first by the practical nurse (PN)? A. A ten-year-old taking amoxicillin (Amoxil) who had two diarrheal stool today. B. A 65-year-old taking erythromycin (E-Mycin) who is reporting gastric distress. C. A thirteen-year-old with asthma who just vomited following a spell of coughing. D. A forty-five year-old with multiple sclerosis who walks with an unsteady gait.
C. A thirteen-year-old with asthma who just vomited following a spell of coughing. Rationale: Particularly in pediatric clients with asthma, coughing until vomiting (C) can be a sign of an asthma exacerbation and requires further assessment. Diarrhea is a common side effect of amoxicillin (A) and gastric upset is a common side effect of erythromycin (B), so these problems do not require immediate intervention by the PN. An unsteady gait (ataxia) is a common symptom of multiple sclerosis that is not indicative of an emergent change in the client's condition (D).
The practical nurse (PN) is reviewing the morning laboratory results for a group of assigned clients. Which finding should the PN report to the healthcare provider first? A. A female client with dysuria and urinalysis reveals presence of 3 to 5 white blood cells. B. Male client with Hepatitis B exposure has positive serum results for Hepatitis B core antibody. C. An older client who has received heparin for two weeks with a platelet count of 15,500/mm3. D. A young adult with rhinorrhea and common cold with an eosinophils count of 20%.
C. An older client who has received heparin for two weeks with a platelet count of 15,500/mm3. Rationale: The client in with thrombocytopenia (normal platelets 150,000 to 400,000/mm3) (C) is likely experiencing a complication due to heparin therapy, and requires timely intervention to prevent bleeding. (A) is not significantly abnormal. (B) is an expected finding. (D) is a typical elevation with allergies
An older male client who drove himself to the emergent care clinic with chest pain is placed on a cardiac monitor with oxygen per nasal cannula at 2 liters/minute as an IV access is obtained. Which intervention should the practical nurse implement first? A. Review history for cardiac disease. B. Collect blood specimens for laboratory studies. C. Apply telemetry electrodes to the client's chest. D. Administer sublingual nitroglycerin.
C. Apply telemetry electrodes to the client's chest. Rationale: Since the client is presenting with chest pain, the risk of becoming unstable at any time due to possible acute coronary syndrome (ACS) requires that differential assessments are implemented immediately. First telemetry electrodes (C) should be applied for early recognition of ST segment changes and life threatening arrhythmias. Although (A) provides information about the client's risk for ACS, the immediate need is analysis of cardiac rhythm. Specimens for diagnostic analysis (B) should be obtained after cardiac rhythm assessment, so treatment, such as the need for nitroglycerin (D) can be prescribed and implemented
The practical nurse (PN) who is the charge nurse in an extended care facility works with two unlicensed assistive personnel (UAPs) who consistently do not take a lunch break. What action should the PN take? A. Seek financial authorization to pay them overtime. B. Ensure adequate coverage is available for breaks. C. Ask UAPs why they are not taking lunch breaks. D. Allow them to take their daily break while charting.
C. Ask UAPs why they are not taking lunch breaks. Rationale: Legally, staff should take a break away from client responsibilities because staff who take lunch breaks can provide more effective and safe client care. The PN should first determine the reasons the UAPs are not taking a lunch break (C). Then, the staff's responsibilities should be adequately covered during the lunch time the UAPs are away from the client (B). (A) is not on a routine practice. During break, staff should be relieved of job-related duties (D).
Following hip replacement surgery, an older male client tells the practical nurse (PN) that he lives alone in a second story apartment. What action is most important for the PN to take? A. Chart the client's comments. B. Share the comment in shift report. C. Contact a hospital case manager. D. Inform the primary care provider.
C. Contact a hospital case manager. Rationale: Living on a second floor apartment impacts the client's ability to return home. The PN should report the finding to the case manager (C), who can best assist the client by ensuring that a safe plan is in place for the care of the client after discharge. Although (A and B) provide a communication link, the issue should be addressed by the case manager who can make additional referrals to assist the client at home. The healthcare provider (D) focuses on the client's medical management, but the case manager coordinates social services and resources to help meet the client's needs during recovery at home.
The practical nurse (PN) stops to help an unconscious victim at the site of a motor vehicle collision. After Emergency Medical Services (EMS) arrive, the PN reports that first aid was rendered and then leaves. The victim dies on the scene from the injuries sustained. What is the PN's liability? A. Criminal assault and battery. B. Negligent acts of omission. C. Good Samaritan immunity. D. Client abandonment.
C. Good Samaritan immunity. Rationale: Based on the good Samaritan act (C) the PN rendered emergency care in good faith at the scene of the accident and is immune from civil liability for actions while providing care. The PN did not violate the status of Nurse practice act
When monitoring a newborn, which observation should the practical nurse report to the healthcare provider? A. Rectal temperature of 37.6° C. B. Axillary temperature of 37.1° C. C. Heart rate of 110 beats per minute. Correct D. Respiration rate of 40 breaths per minute.
C. Heart rate of 110 beats per minute Rationale: The normal range for a heart beat for an infant is 120-160 so a heart rate of 110 should be reported to the healthcare provider. Newborn temperature ranges from 97.7,99.4,36.5,37.5 and normal respiratory rate is 30-60
The practical nurse (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 pnuemothorax to the nurse? A. Evaluate the client's ventilatory effort against the ventilator. B. Check the ventilator pressure settings. C. Inspect the trachea to see if it is midline. D. Determine if an emergency thoracotomy tray is available.
C. Inspect the trachea to see if it is midline. Rationale: Tension pnuemothorax can occur when an emphysematic bullae or blebs ruptures causing air to accumulate in the pleural space and collapsing the lung. Additional findings are needed to differentiate the onset of right sided heart failure versus tension pneumothorax, which is manifested by worsening respiratory status, decreased breath sounds on the affected side, distended neck veins, and tracheal deviation from midline (C). The client's findings are due to a pneumothorax, not resisting the ventilator (A). Although (B) should be implemented, pressure changes do not resolve air accumulation with each inspiration. Although emergency insertion of a chest tube is indicated, the thoracotomy tray (D) can be obtained after additional data is reported to the nurse and healthcare provider
An unemployed female client who is receiving chemotherapy shares with the practical nurse (PN) that it has been devastating for her to become bald. What action should the PN take? A. Report the client's statements during shift change. B. Explain that most clients lose their hair during treatment. C. Investigate potential resources to help obtain a wig. D. Suggest counseling for body-image issues.
C. Investigate potential resources to help obtain a wig. Rationale: Losing one's hair is often a devastating cosmetic consequence of chemotherapy (CT), so investigating potential resources to help the client obtain a wig (C) addresses the client's alterations in self image. Although (A) may be beneficial to the client's overall care, hair loss is the client's stated distress that should be addressed directly. (B) provides the client with information about CT but does not address the client's immediate reaction to alopecia. Although (D) may be indicated to help with client cope with issues related to loss, the client is expressing her need for help with baldness
The practical nurse (PN) enters a client's room at 0900 to administer a heparin injection that is prescribed BID. The physical therapist is in the middle of providing bedside therapy. What action should the PN take? A. Ask the therapist to stop and step out for the medication administration. B. Administer medication while the therapist continues the therapy. C. Leave with the medication and come back after the therapist is finished. D. Take the injection and administer it at the next administration time.
C. Leave with the medication and come back after the therapist is finished. Rationale: Since the heparin injection does not require immediate administration, the best action is to allow the professional colleague to finish the therapy session and then return to give the medication within the allowed hour after the scheduled time (C). Interrupting the therapy session (A) does not respect the importance of the therapist's role in the client's care. It is not necessary to administer two non-emergent therapies at the same time (B). (D) omits one of the prescribed dosages
What client behavior illustrates to the practical nurse that a male client is adapting to the effects of his recent surgery for laryngeal cancer? A. Has a lack of facial tension. B. Selects appropriate foods to eat. C. Looks at surgical site during care. D. Welcomes visitors with a smile.
C. Looks at surgical site during care. Rationale: Surgical intervention for cancer of the larynx includes laryngectomy and radial neck dissection. The willingness to touch or look at the affected area (C) is the best indication that the client acknowledges and accepts the change in appearance. Lack of facial tension (A) or a pleasant social demeanor (D) may be an indication of denial. Although selecting the appropriate foods (B) is important, it does not necessarily reflect the client's adaptation to the change in his body image
The practical nurse (PN) is monitoring a client who is 3 hours post-cardiac catheterization of the right femoral artery. Which client finding requires further action by the PN? A. Right leg with 1+ to 2+ edema. B. Ecchymosis at femoral puncture site. C. Loss of right pedal pulse. D. Blood pressure of 154/88.
C. Loss of right pedal pulse. Rationale: Loss of a pedal pulse (C) is indicative of thrombus or embolism in the right femoral artery and requires immediate follow-up to prevent distal tissue damage. (A) is not a critical finding that requires action at this time. (B) is an expected finding due to arterial puncture. Although stress or pain can cause an elevation of blood pressure (D), the priority finding is obstructed perfusion that obliterates the pulse
Which early finding for a client with a new cast for a fractured leg should the practical nurse report to the charge nurse? A. Reports cast feels cold. B. Pain at fracture site. C. Paresthesia of affected leg. D. Loss of pedal pulse.
C. Paresthesia of affected leg. Rationale: A cast that is too tight causes pressure that decreases blood flow to the affected limb resulting in compartment syndrome, resulting in a change in sensation, or paresthesia (C), which should be reported to the charge nurse. It is normal for a plaster cast to feel cold (A) when it is completely dry. Pain at the fracture site (B) is expected unless it is unrelenting after medication, which is another sign of compromised circulation. Compression of blood vessels with a loss of the pulse (D) is a late sign that circulation is totally occluded.
At the beginning of the shift, the practical nurse (PN) is reconciling a client's medication administration record, the prescriptions, and the dispensed drugs. Which available medication should the PN give? A. Prescribed digoxin (Lanoxin); dispensed digoxin immune FAB (DigiFab). B. Prescribed nitroglycerin (Nitrogard, transmucosal); dispensed nitroglycerin (Nitrostat SL). C. Prescribed albuterol (Proventil); dispensed albuterol (Ventolin). D. Prescribed verapamil (Isoptin); dispensed verapamil SR (Calan SR).
C. Prescribed albuterol (Proventil); dispensed albuterol (Ventolin). Rationale: Albuterol (Ventolin and Proventil) are the same drug, and should be administered as prescribed. (A, B, and C) are the not the same drug and should not be administered as Trade or generic equivalents
A client who is receiving oxygen (O2) at 35% per mask receives a prescription for a trial weaning of O2 to 4 liters/minute per nasal cannula. The practical nurse (PN) notes the client's pulse oximeter reading goes from 96% to 90% after two minutes with the change in O2 administration. What action should the PN take? A. Document the client is tolerating O2 at 4 L/cannula. B. Encourage the client to take several deep breaths. C. Reapply the O2 at 35% per mask. D. Increase the O2 to 6 L/cannula.
C. Reapply the O2 at 35% per mask. Rationale: An accurate evaluation of the client's tolerance to a change in the administration of O2 concentration is best determined 20 minutes after the new oxygen level is initiated. However, the rapid drop in the client's O2 saturation indicates that the client is not tolerating the weaning of O2, so O2 at 35% mask should be resumed (C) and the healthcare provider notified. (A) is incorrect. Although (B) may be helpful in aerating the lung fields, the client is not able to maintain adequate oxygenation. (D) is not indicated.
What finding is most important for the practical nurse to consider before ambulating an older client? A. Length of intravenous tubing. B. History of Alzheimer's disease. C. Use of assistive devices. D. Time the client last voided.
C. Use of assistive devices. Rationale: To ensure the client's safety, it is most important to determine if any assistive devices are needed prior to ambulation (C). Although (A, B, and D) provide useful information, they do not have the importance of (C).
Which task could the practical nurse assign to an unlicensed assistive personnel (UAP)? A. Reinforce teaching a mom how to position infant for sleep. B. Observe and record the presence of an infant's Moro reflex. C. Verify identification arm bands when infant is left in mom's room. D. Determine adequacy of mother's first void after catheter removal.
C. Verify identification arm bands when infant is left in mom's room. Rationale: Delivering an infant from the nursery to the mother's room and verifying the identification on both arm bands is a task that could be assigned to a UAP (C). The task is a predictable, routine task on a unit. Reinforcing teaching about infant sleeping positions (A), assessing for normal infant reflexes (B), and determining adequacy of the quantity of urine output after a catheter (D) require nursing judgment and should not be assigned. Assigned tasks are tasks that nursing assistants are trained, hired, and paid to perform
What is the first action the practical nurse (PN) should take when assisting with the care of a healthy newborn immediately after birth? A. Assess the body temperature. B. Place identification bracelets on mother and baby. C. Verify the establishment of respirations. D. Dry the newborn's skin surfaces.
C. Verify the establishment of respirations. Rationale: The first action is to verify that respirations are established (C). (A and B) should be implemented after ensuring a patent airway and breathing are adequately oxygenating the neonate. (D) is often implemented simultaneously to minimize cold stress complications, but the priority is oxygenation.
Which technique should the practical nurse implement when providing care to a pediatric client? A. Weigh the mother and infant together then subtract the mother's weight. B. Tell a 5-year-old child to blow bubbles during an invasive painful procedure. C. Pinch the child's nose shut to encourage child to swallow oral medications. D. Administer intramuscular injections in the vastus lateralis for a 9-month-old.
D. Administer intramuscular injections in the vastus lateralis for a 9-month-old. Rationale: The vastus lateralis site should be used for an infant (D) until other intramuscular sites develop, which occurs as the child learns to walk. (A) does not provide the most accurate data. (B) is a distraction technique, which may not be effective during invasive painful procedures. (C) places the child at risk for aspiration and is not an acceptable approach.
The practical nurse (PN) arrives at the scene of a mass casualty community disaster. Which victim should the PN triage for immediate transport to the hospital for additional care? A. Older male with an obvious arm deformity who did not take his medicine today. B. Woman who is 8-months pregnant with multiple facial lacerations. C. Preschooler who is complaining of ear pain and has yellow nasal discharge. D. An adolescent male with mouth burns and singed nasal hairs.
D. An adolescent male with mouth burns and singed nasal hairs. Rationale: The victim with singed nasal hairs (D) has inhaled flames or hot smoke and is at risk for swelling of the airways, which requires preemptive intubation to avert an expected possible life-threatening respiratory closure and arrest. (A) can be transported about the possible closed fracture site is splinted. (B) is not manifesting signs of impending delivery, and lacerations can be repaired up to 12 hours after the injury. (C) is not a priority for immediate transport.
A male client is eating at his bedside table and suddenly starts gagging, is unable to talk, and places both hands over his throat. Which action should the practical nurse implement? A. Provide manual ventilation with a mask bag. B. Give five back blows or slaps. C. Use a blind finger sweep inside the mouth. D. Apply successive abdominal thrusts.
D. Apply successive abdominal thrusts. Rationale: Abdominal thrusts, also known as the Heimlich maneuver (D), should be performed to loosen the obstructing foreign body. The client's airway is obstructed and (A) is ineffective. Back blows (B) and a blind finger sweep of the mouth (C) are not recommended actions for obstructed airway
The practical nurse (PN) is visiting a client with a colostomy and notes excoriated skin around the stoma opening. What information should the PN provide? A. Eliminate acidic foods from diet. B. Empty colostomy bag more often. C. Apply over-the-counter steroid cream. D. Cut a smaller opening in the adhesive.
D. Cut a smaller opening in the adhesive. Rationale: The most common cause of skin excoriation is from the adhesive appliance opening that is cut too large and allows fecal matter to come in contact with the skin (D). Excoriated skin is not related to diet intake (A), which affects stool consistency and odor. Emptying the bag more often is not related to the skin irritation (B), unless the bag is leaking from being too full. The application of protective creams (C) or prescriptions may help healing, but peristomal skin excoriation will not resolve without eliminating the cause.
A client who is receiving continuous oxygen is going home after discharge from the hospital. The practical nurse (PN) discovers that oxygen has not been delivered to the client's home. What priority action should the PN implement? A. Send the client home with an oxygen tank from the hospital. B. Notify the home agency of the issue. C. Provide client with equipment company's contact information. D. Delay the time of the client's discharge.
D. Delay the time of the client's discharge. Rationale: The client should not be released until the necessary equipment or supplies are delivered to the client's home to safely continue the client's necessary treatment (D). Sending the client home with a hospital tank (A) does not resolve the issue continuous oxygen available at home. Notifying the home agency (B) of the issue should be done, but is not as important as keeping the client at the hospital with oxygen until the issue is resolved. Providing the equipment company contact information to the client (C) should be done, but is not the priority at this time.
Which action should the practical nurse implement when administering an 8 ounce can of a concentrated nutritional formula via a client's gastrostomy tube (GT)? A. Determine the gastric residual's pH before starting the feeding at prescribed rate. B. Obtain stool specimen for culture of diarrhea stool that occurred after first feeding. C. Discards 60 ml of gastric residual before giving formula. D. Give 30 ml of tap water after administration of formula.
D. Give 30 ml of tap water after administration of formula. Rationale: After administering formula additional water should be given to prevent obstruction of the GT and provide the client with additional hydration
The practical nurse (PN) is caring for a client in a weight reduction program. Which client behavior is the best indicator to the PN that the client is applying the knowledge gained from the program about weight loss? A. Requests a diet brochure to read. B. Lists correctly foods high in fat. C. Discusses feelings about dieting. D. Loses five pounds in three weeks.
D. Loses five pounds in three weeks. Rationale: A change in behavior with measurable results, such as 5 pound weight loss in 3 weeks (D) is the best indicator of the client's application of the weight loss program. The client may not read or apply the information in the brochure (A). Knowledge of high fat foods does not ensure the client's application of modifying the diet (B). Discussing feelings (C) may assist the client to apply the weight reduction program, but the best evaluation of participation in the program is the client's weight loss
Which action is most important for the practical nurse (PN) to implement for a client who has a Stage I pressure ulcer? A. Debride ulcer using a wet to dry dressing. B. Apply an antibiotic ointment to the wound. C. Encourage intake of additional vitamin C. D. Monitor client's serum pre-albumin levels.
D. Monitor client's serum pre-albumin levels. Rationale: Wound healing requires good nutritional status that is best evidenced with serum pre-albumin levels (D) which provide the most useful marker of what the client has eaten, what nutrients the client has absorbed, digested and metabolized. A stage I ulcer does not require debridement (A) or an ointment (B). An adequate intake of vitamin C is important for wound healing but serum pre-albumin gives a better overall picture of the client's nutritional status (C).
A female client reports to the practical nurse (PN) that she has had 10 watery diarrhea stools in the last 24 hours and is feeling dizzy. Which intervention should the PN implement first? A. Review the client's white blood cell count. B. Ask if she has recently traveled to foreign country. C. Collect a stool sample for culture for C. difficile. D. Obtain her vital signs lying and standing.
D. Obtain her vital signs lying and standing. Rationale: The client is experiencing fluid volume deficit related to diarrhea and dehydration evidenced by feeling dizzy, so the client's lying and standing vital signs (D) should be implemented first to identify orthostatic changes that require additional intervention. Although (A, B, and C) should be implemented, assessment of the client's status should be determined first to provide safe care.
The practical nurse (PN) is caring for a client who is receiving chemotherapy for cervical cancer who is scheduled to go for a chest xray. Current laboratory results include hemoglobin 10.0 grams/dl, absolute neutrophil count (ANC) of 500, platelets 120,000/mm3, and white blood cells 4,000/mm3. What action should the PN implement first? A. Notify healthcare provider about laboratory results. B. Compare client's results with past laboratory values. C. Examine the client for the presence of ecchymosis. D. Place a protective mask on the client for transport.
D. Place a protective mask on the client for transport. Rationale: The client is immunosuppressed due to a side effect of chemotherapy, as evidenced by the client's ANC (which is calculated daily using # WBC x % neutrophils). If the ANC is less than 1,000, protective precautions (reverse isolation) is indicated, so the PN should place a protective mask on the client for transport to xray (D). (A, B, and C) are implemented after (D).
Which protocol regarding standard policies about prescriptions should the practical nurse (PN) question? A. All drug prescriptions should have the date, time, and prescriber's signature. B.Verbal orders are accepted from prescribers and should include signatures. C. Prescribers may write specific times at which the medications are to be given. D. Preoperative prescriptions should be resumed after a client returns from surgery
D. Preoperative prescriptions should be resumed after a client returns from surgery. Rationale: A standard policy about preoperative medications that preoperative prescriptions are automatically canceled for surgery and should be rewritten, if indicated , in the postoperatively so the (PN) should question (D). (A,B,C) are correct statements.
A male client who is paraplegic due to a diving accident is admitted to the rehabilitation unit. Which finding is most important for the practical nurse (PN) to report to the interdisciplinary team? A. Reduction of appetite, 50% of meals eaten. B. Stage I decubitus on right heel. C. Discharge plan to a second-floor apartment. D. Repeated refusals to see any visitors.
D. Repeated refusals to see any visitors. Rationale: The client's refusal to see visitors (D) is a sign of social isolation that is consistent with clinical depression. (A, B, and C) should be reported, but the most important finding is the client's isolation which may impact his participation in his rehabilitation plan of care.
A client who was struck by a baseball on the right temple is admitted for 24-hour observation. What finding should the practical nurse (PN) report to the nurse immediately? A. Complains of feeling dizzy. B. Red blood oozing from a facial laceration. C. Heart rate 110 beats/minute; blood pressure 130/70. D. Right pupil size 9 mm; left pupil size 6 mm.
D. Right pupil size 9 mm; left pupil size 6 mm. Rationale: Anisocoria, or unequal pupil size (D), is a sign of intracranial compression after head injury and should be reported immediately for follow-up management. (A) is a common finding following a head injury. The face is highly vascular, so (B) is not unexpected. (C) can be slightly elevated due to pain and anxiety and are not in a critical finding
The practical nurse (PN) administered furosemide (Lasix) 60 mg PO instead of the client's prescribed dose of 20 mg. What action is most important for the PN to implement? A. Complete an adverse occurrence report. B. Record dose on the medication administration record. C. Reinforce with the client about the side effects of Lasix. D. Take client's blood pressure in an hour.
D. Take client's blood pressure in an hour. Rationale: The onset of oral dosing of Lasix is 30-60 minutes, peaking 60-70 minutes after administration. Blood pressures should be monitored in an hour (D) to identify signs of hypovolemia during periods of diuresis. (A) is not indicated unless the client experiences a severe adverse response. Documentation (B) is implemented after drug administration. Although the client should be aware of side effects (C), the priority is assessment for adverse effects during the peak action of oral Lasix.
Which observation by the practical nurse (PN) indicates that a piece of medical equipment is not functioning properly? A. The digital bedside glucose meter displays the word HI. B. A pulse oximeter indicates it is unable to detect a pulse. C. The bed alarm sounds an audible alarm when client sits up. D. The sphygmomanometer's reading drops without a knob turn.
D. The sphygmomanometer's reading drops without a knob turn. Rationale: The blood pressure reading that is not controlled by the knob (D) on the cuff indicates a malfunction of the equipment. (A) is a function that is set by the manufacturer to indicate an extremely elevated blood sugar. A pulse oximeter does not display (B). (C) is a function that warns the staff that a client is attempting to get out of bed without assistance.
The practical nurse is assisting with moving clients into semiprivate rooms so other rooms can be made available for the admission of victims of a community disaster. Which two clients should be placed in the same room? A. Two clients on contact precautions for skin and wound infections caused by different bacteria. B. A toddler with Rubeola measles and an infant with bacterial pneumonia. C. One client in airborne precautions and another client in droplet precautions. D. Two clients on universal precautions, one for asthma exacerbation, the other with heart failure.
D. Two clients on universal precautions, one for asthma exacerbation, the other with heart failure. Rationale: Two non-infectious clients on universal precautions should be placed in the same room (D). (A, B, and C) are susceptible to nosocomial transmission of each others' infectious agent.
The healthcare provider prescribes ketorolac (Toradol) 15 mg IM for a client in pain. The available concentration is 30 mg/ml. How many ml should the practical nurse (PN) administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
•0.5 Using ratio and proportion, 30 mg : 1 ml :: 15 mg : X 30X = 15 X = 0.5 ml
The practical nurse (PN) is preparing to administer azithromycin (Zithromax) 500 mg PO for a client with pneumonia. The medication is available as a suspension that is labeled, 200 mg/5 ml. How many ml should the PN administer? (Enter numeric value only. If rounding is required, round to the nearest tenth
•12.5 Using ratio and proportion calculation, 200 mg : 5 ml :: 500 mg : X 200X = 2500 X = 12.5 ml
A client receives a prescription for diltiazem (Cardizem) at 5 mg/hour. The drug is dispensed as 125 mg in 100 ml D5W. How many ml/hour should the practical nurse (PN) program the infusion pump?
•4 125 mg divided by 100 ml = 1.25 mg/ml = concentration of the Cardizem solution Using the formula, D/H x Q, 5 mg/1.25 mg x 1 ml = 4 ml/hour
