Fundamentals - HESI : PN
An older adult client calls the clinic reporting weakness and dizziness. Further data collection by the practical nurse (PN) indicates that the client self-administered an enema of 3 L of tap water to relieve constipation. What is the most likely cause of the client's symptoms? a. Mucosal bleeding b. Sodium retention c. Fluid volume depletion d. Water intoxication
d. Water intoxication Rationale: Tap water is a hypotonic fluid, which can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication. This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress.
The practical nurse (PN) is preparing to administer a prescribed dose of digoxin 125 mcg PO. The medication available is 0.25 mg per tablet. How many tablets should the PN administer? (Fill in the blank. Type in numbers only and round to the nearest tenth.) ____tablet
0.5 Rationale: 125 mcg × 1 mg/1000 mcg × 1 tablet/0.25 mg = 0.5 tablet
The nurse is assigned to care for 4 clients this shift. Based on information provided in the change of shift report at 0700, in which order should the nurse see the clients? Arrange the sequence options in the correct order by assigning each option a number. A) A client who will be going for throat surgery at noon today. B) A client whose blood sugar was 68 and was given oral glucose at 0600. C) A client who has discharge orders, but is awaiting a ride home. D) A client who was admitted at 0500 who has pneumonia and requires frequent suctioning.
1 - D) A client who was admitted at 0500 who has pneumonia and requires frequent suctioning. 2 - B) A client whose blood sugar was 68 and was given oral glucose at 0600. 3 - A) A client who will be going for throat surgery at noon today. 4 - C) A client who has discharge orders, but is awaiting a ride home. Rationale: Use the principle of airway, breathing, and circulation (ABC) to assist with priority setting. The client who requires frequent suctioning and has pneumonia should be seen first. After that, the client whose blood sugar had been treated should be seen. The client who will be undergoing throat surgery should be seen next, to ensure that the client is fasting and is ready for surgery. The client who is awaiting a ride home can be seen last.
The practical nurse (PN) is assisting a client to ambulate with a cane. Arrange the steps in ascending order from the first task to the last task. All options must be used. Arrange the sequence options in the correct order by assigning each option a number. A) Have the client advance the cane and the affected leg. B) Apply a gait belt to the client. C) Have the client hold the cane in the hand of the unaffected extremity. D) Explain the procedure to the client. E) Have the client lean on cane while moving unaffected leg forward.
1 - D) Explain the procedure to the client. 2 - B) Apply a gait belt to the client. 3 - C) Have the client hold the cane in the hand of the unaffected extremity. 4 - A) Have the client advance the cane and the affected leg. 5 - E) Have the client lean on cane while moving unaffected leg forward. Rationale: First, the PN should explain the procedure to the client; second, a gait belt should be applied to provide improved safety for both the PN and the client during ambulation; third, the cane should be held in the unaffected extremity; fourth, the cane and the affected leg should be advanced; and fifth, the client should lean on the cane while moving the unaffected leg forward.
The nurse comes upon the scene of an automobile accident involving many cars. In which order should the nurse provide care to the victims? Arrange the sequence options in the correct order by assigning each option a number. A) The victim who is not breathing and does not have a pulse. B) The victim who is crying, and looking for a family member. C) The victim whose right leg is bent from an obvious fracture. D) The victim who is heavily bleeding bright red blood from a thigh wound.
1 - D) The victim who is heavily bleeding bright red blood from a thigh wound. 2 - C) The victim whose right leg is bent from an obvious fracture. 3 - B) The victim who is crying, and looking for a family member. 4 - A) The victim who is not breathing and does not have a pulse. Rationale: When the nurse is the only health care provider on the scene, the nurse must provide care to those who are most likely to survive. The client hemorrhaging from the leg wound is the priority, and the nurse should apply pressure to the wound, or take other measures to control bleeding. The victim whose leg is broken should be cared for next. The victim who is crying and looking for a family member should be cared for after that. The victim who is not breathing and does not have a pulse is dead.
An older adult client has been diagnosed with Clostridium difficile (C. Diff)-associated diarrhea. Which is the best method to prevent transmission of the disease to other clients in the long-term care facility? a. Adequate handwashing with soap and water b. Conducting cultures of all the employees' stools c. Asking staff members to stay home if they develop diarrhea d. Installing alcohol based hand sanitizer inside each client's door
A) Adequate handwashing with soap and water Rationale: The organism that causes C. Diff-associated diarrhea is not killed by alcohol-based hand sanitizers. Adequate handwashing with soap and water is the best way to prevent the spread of the disease since it helps remove most of the microorganism on the hands of staff members. Employees should stay home if they develop diarrhea, but this is not specific to C. Diff-associated diarrhea. Collecting stool samples from employees would not stop the spread of the disease.
The nurse asks an unlicensed assistive personnel (UAP) to give a client a sitz bath to treat the client's painful hemorrhoids. The UAP states "I've never done that before, what is that?" What is the most appropriate action for the nurse to take? a. Ask another UAP who has done the procedure previously to administer the treatment. b. Report the UAP to the nursing director for refusing to carry out the nurse's instructions. c. Give the UAP verbal and written instructions, and then ask the UAP to carry out the treatment. d. Provide the UAP with the agency policy and procedure manual and ask if the UAP is ready now to administer the treatment.
A) Ask another UAP who has done the procedure previously to administer the treatment. Rationale: The nurse is required to assign tasks to the "right person"; that is, a person who is qualified to undertake the task. In this instance, the UAP has stated they have not done the procedure before, so it would be inappropriate to assign this task. The best approach is to assign the task to someone who has previously performed the task. There is no reason to notify the nursing director, because the UAP has a legitimate concern with administering the treatment. It is also not appropriate to merely provide instructions and then ask the UAP to carry out the treatment without verification that the UAP is capable of performing the task.
While performing colostomy care, the practical nurse (PN) observes skin irritation around the stomal site. What action should the PN take when reapplying the colostomy bag? a. Ensure that the hydrocolloidal stomal wafer covers the peristomal skin. b. Apply petroleum jelly around the stomal site and under the wafer. c. Do not irrigate the colostomy for 7 to 10 days until irritation is gone. d. Wash the area around the stomal site with povidone-iodine and leave open to the air.
A) Ensure that the hydrocolloidal stomal wafer covers the peristomal skin. Rationale: *Hydrocolloid stomal wafers should be measured precisely to ensure peristomal skin coverage and protection from irritation and breakdown. *The stomal site should be cleansed gently with a moist, soft cloth and mild soap and another bag applied to prevent skin contact with fecal drainage.
When should the practical nurse (PN) evaluate the client's pain level? (Select all that apply.) a. Routinely with measurement of vital signs b. When the client initially complains of pain c. At the beginning and end of each shift d. Every 4 hours around the clock e. 30 to 60 minutes after administration of an analgesic
A) Routinely with measurement of vital signs B) When the client initially complains of pain C) At the beginning and end of each shift E) 30 to 60 minutes after administration of an analgesic Rationale: The client's pain level should be assessed routinely with measurement of vital signs, when the client initially complains of pain, at the beginning and end of a shift. Assessment of effectiveness should occur 30 to 60 minutes after administration of an analgesic. The client should not be awakened while sleeping for assessment of his/her pain level.
The nurse is shopping at a mall when an individual with a large machete suddenly starts stabbing other shoppers. Security police have captured the assailant. Multiple shoppers and mall employees immediately left the premises. Which victim should the nurse attend first until first responders arrive? A) An individual whose head is completely severed. B) An individual with a pulsating gash to the forearm. C) An individual whose ankle was twisted running from the scene. D) An individual who has no palpable pulse and no respiratory effort.
B) An individual with a pulsating gash to the forearm. Rationale: The nurse should attend to the individual with a pulsating gash to the forearm. It is likely the nurse can slow the bleeding by applying direct pressure or a tourniquet to the arm. The individual whose head is completely severed is dead. The individual who has no pulse would require a great deal of resources while the individual whose arm is severed could be attended to by one individual. The individual with a twisted ankle can be treated at a later time.
The HIV unit nursing team, composed of the registered nurse (RN) case manager, staff RNs, and staff practical nurses (PNs), is meeting to discuss a client who has developed anorexia related to HIV medications. The client has lost 15 pounds in the previous 2 months. Which action should the team implement to continue the nursing process? a. Plan interventions to improve the client's appetite. b. Collaborate with the client to set goals. c. Develop outcome statements for use in evaluation. d. Determine the cause of the anorexia and weight loss.
B) Collaborate with the client to set goals. Rationale: The client has been assessed and the cause determined, so the next step in the nursing process is to collaborate with the client to set goals. When clients are included in the nursing process, the plan of care becomes more client-focused.
Which client finding requires further action by the practical nurse (PN)? a. A disoriented client's soft wrist restraints are tied to the bed frame. b. The drainage tube of an indwelling catheter is looped below the client's bladder. c. The aspirant of a client's nasogastric tube has a pH of 4. d. Skin over the coccyx blanches when the client is repositioned to a lateral position.
B) The drainage tube of an indwelling catheter is looped below the client's bladder. Rationale: Urine collecting in a loop of tubing that is dependent will not drain properly and places the client at risk for infection, so the (PN) should reposition the urinary drainage tube to eliminate looping below the bladder.
The nurse has just begun a sterile wound dressing change for a resident at a long-term care facility when the nurse's pager goes off, indicating a health care provider is calling the nurse with prescriptions for a different resident. What should be the nurse's action? a. Remove the sterile gloves, cover the wound with a towel and go answer the phone. b. Ask the unit secretary to take the prescriptions from the health care provider. c. Ask the unit secretary to obtain a call back number for the health care provider. d. Ask the health care provider to provide the prescriptions over the speaker in the resident's room.
C) Ask the unit secretary to obtain a call back number for the health care provider. Rationale: The nurse should ask the secretary to obtain a call back number for the health care provider. The nurse should not stop a sterile procedure and cover the wound with a towel. A licensed nurse, not a unit secretary, must take prescriptions from a health care provider. It would be a violation of client privacy standards for the nurse and provider to discuss orders over the speaker in another resident's room.
Before performing a fecal occult blood test or guaiac test on a stool specimen, the practical nurse (PN) should ask the client about the regular use of which vitamin? a. A b. B1 c. C d. D
C) C Rationale: The guaiac test measures microscopic amounts of blood in feces. A false-positive result can occur from the regular use of vitamin C.
Which instruction should the practical nurse (PN) provide to a client whose vision is being tested with a Snellen chart? a. Stand on a line drawn 10 feet from the chart. b. Read each sentence slowly and carefully. c. Cover one eye while reading the chart with the other. d. Begin by identifying the first line that is hard to read.
C) Cover one eye while reading the chart with the other. Rationale: Each eye should be tested separately because visual acuity can vary from one eye to the other. The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read.
The nurse has several tasks to accomplish during a busy shift on an acute care urology unit. Which task can be delegated to an unlicensed assistive personnel (UAP)? a. Insert an indwelling urinary catheter. b. Assess for symptoms of a urinary tract infection (UTI). c. Measure and record urine output from an indwelling urinary catheter. d. Teach a client how to perform self-care for an indwelling urinary catheter.
C) Measure and record urine output from an indwelling urinary catheter. Rationale: The UAP should be able to measure and record urine output from an indwelling catheter. The role of the UAP does not include sterile procedures, client assessment, and teaching.
A client is undergoing chemotherapy treatment and has a decreased neutrophil count. The client is under protective (reverse, or neutropenic) precautions. While the nurse is caring for the client, the client hands her cell phone to the nurse and says, "This is my pastor, can you explain to him about this isolation stuff?" Which comments are most appropriate for the nurse to make? (Select all that apply.) a. "Her white blood cells are dangerously low right now." b. "She would probably enjoy visits from your preschool choir." c. "If her white blood cells drop any further, she will be on isolation a long time." d. "I think she would benefit from members of the congregation phoning her." e. "She can communicate with others via email or texting." f. "Could you send her flowers from your congregation?"
D) "I think she would benefit from members of the congregation phoning her." E) "She can communicate with others via email or texting." Rationale: A client under protective (reverse or neutropenic) precautions due to an increased risk of infection due to a low neutrophil count. The client can communicate with others via phone, email or texting. The client cannot have visits from children, and cannot have flowers or plants in the room, due to a risk of infection. It is a violation of client privacy rights to discuss the client's white blood cells counts. The client asked the nurse to provide information about the precautions in place, not her white blood cells.
The practical nurse (PN) is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later, the client reports that the insomnia continues despite following the same routine every night. What action should the PN take first? a. Instruct the client to add a daily routine of regular exercise. b. Determine if the client has been keeping a sleep diary. c. Encourage the client to continue the routine until sleep is achieved. d. Ask the client to describe the current routine practiced by the client.
D) Ask the client to describe the current routine practiced by the client. Rationale: The PN should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information.
After receiving reinforcement of written and verbal instructions from the clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? a. Provide the client with a list of Internet sites that answer frequently asked questions about medications. b. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. c. Reassure the client that all necessary information about the medication is included in the written instructions. d. Encourage the client to call the clinic nurse, pharmacist or the health care provider if any questions arise.
D) Encourage the client to call the clinic nurse, pharmacist or the health care provider if any questions arise. Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse, pharmacist, or health care provider if any questions arise. Options A, B, and C could possible not provide all the necessary information, and also do not allow a health care professional to evaluate the need for follow up.
The practical nurse (PN) recognizes which aspect of care has the highest priority for a client with an indwelling urinary catheter? a. Promoting self-care b. Preventing incontinence c. Ensuring hydration d. Preventing infection
D) Preventing infection Rationale: Indwelling urinary catheters are a high source of infection.
The practical nurse (PN) is performing nasotracheal suctioning. After the client's trachea is suctioned for 10 seconds, large amounts of thick yellow secretions return. What action should the PN implement next? a. Encourage the client to cough to help loosen secretions. b. Advise the client to increase intake of oral fluids. c. Rotate the suction catheter to obtain any remaining secretions. d. Reoxygenate the client before attempting to suction again.
D) Reoxygenate the client before attempting to suction again. Rationale: Suctioning should not be continued for longer than 10 seconds because the client's oxygenation is compromised during this time.
Which serum laboratory value should the practical nurse (PN) monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? a. White blood cell count b. Albumin c. Calcium d. Sodium
D) Sodium
An older adult client has been diagnosed with Clostridium difficile (C. Diff)-associated diarrhea. Which is the best method to prevent transmission of the disease to other clients in the long-term care facility? a. Adequate handwashing with soap and water b. Conducting cultures of all the employees' stools c. Asking staff members to stay home if they develop diarrhea d. Installing alcohol based hand sanitizer inside each client's door
a. Adequate handwashing with soap and water Rationale: The organism that causes C. Diff-associated diarrhea is not killed by alcohol-based hand sanitizers. Adequate handwashing with soap and water is the best way to prevent the spread of the disease since it helps remove most of the microorganism on the hands of staff members. Employees should stay home if they develop diarrhea, but this is not specific to C. Diff-associated diarrhea. Collecting stool samples from employees would not stop the spread of the disease.
An older adult client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the practical nurse (PN) to consider before assisting this client? a. Blood pressure of 86/54 mm Hg b. 30% of diet eaten c. Oriented to person only d. Inelastic skin turgor
a. Blood pressure of 86/54 mm Hg Rationale: Hypotension places the client at risk for falls because it can cause dizziness. To ensure client safety, it is most important for the PN to be aware of the client's low blood pressure before transfer.
The practical nurse (PN) is administering medications to a client via a nasogastric tube. The 0900 medications include a sustained-release spansule. Which action should the PN take when administering the sustained-release drug via the nasogastric tube (NGT)? a. Consult the health care provider for a different drug form that can be crushed. b. Open the spansule and flush the pellets through the tubing. c. Omit the medication and document the reason. d. Advance the tube into the small intestine before giving the medication.
a. Consult the health care provider for a different drug form that can be crushed. Rationale: Administration of sustained-release (SR) spansules is contraindicated via nasogastric tube so the PN would have to consult the health care provider for a different drug form that can be crushed.
A client is experiencing less sleep than usual due to nocturia. Which client information is important for the practical nurse (PN) to provide? a. Decrease your intake of fluids after the evening meal. b. Drink a glass of cranberry juice every day. c. Drink a glass of warm decaffeinated beverage at bedtime. d. Consult your health care provider about a sleeping pill.
a. Decrease your intake of fluids after the evening meal. Rationale: Decreasing intake of fluids during the evening is helpful to decrease nocturia.
The practical nurse (PN) is the team leader on a 35 resident long-term care unit. Besides the PN team leader, there is another PN and 4 unlicensed assistive personnel (UAPs). Which tasks should the PN assign to the PN, rather than the UAP? (Select all that apply.) a. Phoning the health care provider regarding laboratory tests for a resident b. Assisting a resident who has an unsteady gait to walk to the main dining facility c. Contacting a resident's family regarding a change in the resident's medications d. Determining the cause of a resident's recent onset of confusion and agitation e. Gathering the residents and taking them to the community room for a church service
a. Phoning the health care provider regarding laboratory tests for a resident c. Contacting a resident's family regarding a change in the resident's medications d. Determining the cause of a resident's recent onset of confusion and agitation Rationale: The licensed nurse is responsible for notifying health care providers and family members regarding changes in the resident's condition. The nurse is also the member of the health care team who will assist in determining the cause of a condition change in a resident. In a long-term care facility, the UAP should be able to assist a resident with an unsteady gait, and to gather residents for an activity.
To administer a saline enema to a client, the practical nurse (PN) inserts the enema tubing 3 inches into the client's rectum and elevates the saline container 6 inches above the client's body. After the PN opens the clamp, the saline solution does not infuse. What is the best action for the PN to take? a. Raise the saline container 6 more inches above the body. b. Insert the tubing an additional 3 inches into the rectum. c. Instruct the client to take several slow, deep breaths. d. Remove the tubing and check the client for fecal impaction.
a. Raise the saline container 6 more inches above the body. Rationale: The saline flows by gravity and should be held about 12 inches above the body.
Which instruction is most important for the practical nurse (PN) to provide a client before the client leaves the unit to have magnetic resonance imaging (MRI) performed? a. Remove all metal objects from the body. b. Empty the bladder before leaving the unit. c. Remain motionless during the MRI. d. Use earplugs during the procedure.
a. Remove all metal objects from the body. Rationale: Dental bridges, hair clips, belts, credit cards, jewelry, and patches with a foil backing, such as nicotine patches, can create burns on the client and cause artifacts on the scan, so removing all metal objects from the body is the most important instruction to provide the client before an MRI.
The practical nurse (PN) is applying the finger probe for continuous pulse oximetry on a client. Which actions should help prevent skin irritation or breakdown? (Select all that apply.) a. Rotate the probe location site every 4 to 8 hours. b. Remove fingernail polish with acetone. c. Cleanse the finger with soap and water as needed. d. Secure with gauze if client has allergy to adhesives. e. Apply lotion before attaching the probe.
a. Rotate the probe location site every 4 to 8 hours. c. Cleanse the finger with soap and water as needed. d. Secure with gauze if client has allergy to adhesives. Rationale: Site rotation, skin cleansing, and avoidance of adhesives for allergies should help prevent skin irritation or breakdown.
The practical nurse (PN) is counting a client's respiratory rate. During a 30-second interval, the PN counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the PN counts eight respirations. What respiratory rate should the PN document? a. 14 breaths/min b. 16 breaths/min c. 17 breaths/min d. 28 breaths/min
b. 16 breaths/min Rationale: The most accurate respiratory rate is the second count obtained by the PN, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled.
The nurse is shopping at a mall when an individual with a large machete suddenly starts stabbing other shoppers. Security police have captured the assailant. Multiple shoppers and mall employees immediately left the premises. Which victim should the nurse attend first until first responders arrive? a. An individual whose head is completely severed. b. An individual with a pulsating gash to the forearm. c. An individual whose ankle was twisted running from the scene. d. An individual who has no palpable pulse and no respiratory effort.
b. An individual with a pulsating gash to the forearm. Rationale: The nurse should attend to the individual with a pulsating gash to the forearm. It is likely the nurse can slow the bleeding by applying direct pressure or a tourniquet to the arm. The individual whose head is completely severed is dead. The individual who has no pulse would require a great deal of resources while the individual whose arm is severed could be attended to by one individual. The individual with a twisted ankle can be treated at a later time.
An older adult client who attends an adult day care program and is wheelchair-mobile has redness in the sacral area. Which information is most important for the practical nurse (PN) to provide? a. Take a vitamin supplement tablet once a day. b. Change positions in the chair at least every hour. c. Increase daily intake of water or other fluids. d. Purchase a newer model wheelchair.
b. Change positions in the chair at least every hour. Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers.
Which action should the practical nurse (PN) implement to ensure that eye ointment is distributed evenly across the eye and lid margin? a. Apply the ointment along the upper outer edge of the eyelid from the outer to the inner canthus. b. Instill the ointment along the lower inner edge of the eyelid from the inner to the outer canthus. c. Spread the ointment along the lower outer edge of the eyelid from the outer to the inner canthus. d. Place the ointment along the upper and lower inner edges of the eyelids from the inner to the outer canthus.
b. Instill the ointment along the lower inner edge of the eyelid from the inner to the outer canthus. Rationale: To instill eye ointment, the practical nurse (PN) would hold the ointment applicator above the lower lid margin and apply a thin stream of ointment along the inner edge of the lower eyelid on the conjunctiva from the inner canthus to the outer canthus.
The nurse and an unlicensed assistive personnel (UAP) are assigned 7 patients on an oncology unit. Which tasks should be appropriate for the nurse to assign to the UAP? (Select all that apply.) a. Explaining the side effects of chemotherapy to a client and family b. Obtaining a client's height and weight c. Feeding a client had an eye enucleation 2 days ago d. Calculating the intake and output for a client who is receiving radiation therapy e. Administering routine oral medications to a client while the nurse is busy
b. Obtaining a client's height and weight c. Feeding a client had an eye enucleation 2 days ago d. Calculating the intake and output for a client who is receiving radiation therapy Rationale: The UAP should be able to obtain a client's height and weight, feed a client and calculate intake and output. The licensed nurse is responsible to client/family education and administering medications to clients.
A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and tachypnea. What action should the practical nurse (PN) take first? a. Give oxygen at 2 L per nasal cannula. b. Raise the head of the bed. c. Observe for tracheal deviation. d. Reassure and stay with the client.
b. Raise the head of the bed. Rationale: Raising the head of the bed facilitates respiratory functioning. The first action is that client should be placed in a semi-Fowler's or Fowler's position. Although tracheal deviation can occur with a tension pneumothorax, the client should be placed in an upright position in the bed before further assessment is obtained.
The practical nurse (PN) enters a client's room and finds the client on the floor after a fall. How should the PN communicate this situation to the risk management team? a. Assist the unit manager in completing an incident report describing the situation. b. Submit a completed incident report describing the situation to the unit manager. c. Advise the client's primary nurse of the need to complete an incident report. d. Report the situation to the client's health care provider, who should submit any needed reports.
b. Submit a completed incident report describing the situation to the unit manager. Rationale: Incident reports must be completed by the PN who has first-hand knowledge of the facts of the situation.
A resident at a long-term care facility has chronic migraines which are usually treated with medication, an ice pack and some caffeinated tea. The nurse is in the process of receiving change of shift report when an unlicensed assistive personnel (UAP) reports this client is having a migraine. The nurse instructs the UAP to obtain an ice pack, wrap it in a towel, and apply it to the resident. Instead, the UAP gives the resident over the counter acetaminophen. The UAP also provides the resident with a heating pad which has burned the resident's forehead by the time the nurse enters the resident's room with medication 20 minutes later. The incident is referred to the quality assurance committee who will likely make which determination? a. The nurse's supervisor is at fault for not providing adequate staffing during shift change. b. The UAP is at fault for acting outside of their scope of practice. c. The nurse is at fault for not adequately supervising the actions of the UAP. d. The pharmacy is at fault for having medications within the access of the UAP.
b. The UAP is at fault for acting outside of their scope of practice. Rationale: The nurse is responsible for the actions of those supervised, unless that person acts outside their scope of practice. In this instance, the UAP acted outside their scope of practice by administering medications and by applying a heating pad, which was not requested by the nurse. The nurse did ask the UAP to apply an ice pack wrapped in a towel, which is an appropriate task to delegate to a UAP. There is no information in the question to support the thought there was inadequate staffing during shift change, or that pharmacy was negligent by keeping medications that could be accessed by the UAP.
The nurse at an urgent care center was asked by the center's health care provider to delegate several tasks to unlicensed assistive personnel (UAPs). The nurse questions several of the tasks the provider has asked be delegated. Which source is the BEST source for the nurse to consult prior to delegating these tasks? a. The health care provider's supervisor b. The state's Nurse Practice Act c. The facility policy manual d. The nurse manager of the facility
b. The state's Nurse Practice Act Rationale: The first source to consult is the Nurse Practice Act. Other sources, such as supervisors and facility policy manuals could actually conflict with the Nurse Practice Act. The nurse is responsible for knowing which tasks can and cannot be legally assigned to UAPs.
The nurse at a long-term care facility learns that a new resident will be admitted and that the new resident has methicillin-resistant Staphylococcus aureus (MRSA) cultured from open wounds. The facility does not have any private rooms. The nurse should assign the new resident with which other resident? a. A resident who is taking large doses of prednisone to treat asthma, but has intact skin. b. A resident with no open wounds, but has recently completed treatment for prostate cancer. c. A resident who has several open wounds, with MRSA cultured from one of the wounds. d. A resident who has scabbed over lesions from a recent infection with shingles.
c. A resident who has several open wounds, with MRSA cultured from one of the wounds. Rationale: The resident with MRSA cultured from open wounds should either be in a private room (which is not available) or with another person with the same disorder. MRSA is easily communicable, especially to those with impaired immune systems, such as individuals taking large doses of steroids and those who have undergone treatment with radiation or chemotherapy. Even if the lesions from shingles have scabbed over, that individual is still prone to secondary bacterial skin infections, such as MRSA.
The practical nurse (PN) is administering a rectal suppository to a client. What action should be implemented to prevent discomfort during administration? a. Place the suppository high in the rectum. b. Freeze the suppository before insertion. c. Allow the suppository soften before insertion. d. Avoid use of a lubricant with insertion.
c. Allow the suppository soften before insertion. Rationale: Allowing the suppository to soften slightly before insertion will decrease the possibility of causing trauma or discomfort to the client.
Which instruction should the practical nurse (PN) provide to a client whose vision is being tested with a Snellen chart? a. Stand on a line drawn 10 feet from the chart. b. Read each sentence slowly and carefully. c. Cover one eye while reading the chart with the other. d. Begin by identifying the first line that is hard to read.
c. Cover one eye while reading the chart with the other. Rationale: Each eye should be tested separately because visual acuity can vary from one eye to the other. The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read.
The practical nurse (PN) obtains lying and standing blood pressure measurements for a client who complains of dizziness upon standing up from the computer at work. The PN determines that systolic pressure decreases 24 mm Hg when standing. What intervention is most important for the PN to implement? a. Recommend that the client drink plenty of water every day. b. Determine if the client takes antihypertensive medications. c. Encourage the client to flex both feet before rising slowly. d. Review the client's history for any incidence of syncope.
c. Encourage the client to flex both feet before rising slowly. Rationale: Orthostatic hypotension is a sudden fall in blood pressure, usually greater than 20/10 mm Hg, that occurs when suddenly rising from a sitting or lying position to a standing position. Flexing the feet before rising slowly stimulates skeletal muscle contraction that promotes venous return and helps prevent syncope or injury.
The practical nurse (PN) is caring for a dyspneic client whose oxygen saturation rate is currently 95%. What position is best for this client? a. Supine with the legs slightly elevated. b. Modified left lateral recumbent with a pillow under the upper leg. c. Fowler's with both legs supported. d. Any position that is comfortable.
c. Fowler's with both legs supported. Rationale: In the Fowler's position, the head is elevated 45 degrees, and the individual's knees are slightly flexed, which promotes maximum lung expansion and tracheal alignment. Even though the client's oxygen saturation rate is within normal limits (WNL), this client is having trouble breathing. Sitting up, so that the lungs can fully expand and the trachea is aligned, is usually helpful in promoting breathing.
The practical nurse (PN) is assessing a client's 2 days after post hip replacement surgery. In assessing the client's vital signs, which finding requires the most immediate action by the PN? a. Auscultatory gap b. Diaphragmatic breathing c. Hyperthermia d. Palpable apical impulse
c. Hyperthermia Rationale: Hyperthermia, an elevated body temperature, requires the most immediate action to determine the cause of the fever and contact the health care provider.
Which action is most important for the practical nurse (PN) to implement when donning sterile gloves? a. Maintain the thumb at a 90-degree angle. b. Hold the hands with the fingers down while gloving. c. Keep gloved hands above the elbows. d. Put the glove on the dominant hand first.
c. Keep gloved hands above the elbows. Rationale: Gloved hands held below waist level are considered unsterile.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement should the practical nurse (PN) identify that best demonstrates the client's readiness to manage his/her wound care after discharge? a. The client asks relevant questions regarding the dressing change. b. The client states that he/she will be able to complete the wound care regimen. c. The client demonstrates the wound care procedure correctly. d. The client has all the necessary supplies for wound care.
c. The client demonstrates the wound care procedure correctly. Rationale: A return demonstration of a procedure provides an objective assessment of the client's ability to perform a task.
Which serum laboratory value should the practical nurse (PN) monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? a. White blood cell count b. Albumin c. Calcium d. Sodium
d. Sodium Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning.
A 5-year-old child is hospitalized with complications of rubella (German measles). A hospital maintenance worker is going into the room to repair the television and notes the precautions sign on the child's room. The worker asks the nurse "What's going on in that room? Is there something I could catch?" Which is the best response from the nurse? a. "Have you ever heard of parents who refuse to immunize their children?" b. "Are you very certain that your rubella vaccinations are up to date?" c. "You do not need to go in the room, the child is too sick to watch TV." d. "Make sure you wear a mask, gloves, and gown before you enter the room."
d. "Make sure you wear a mask, gloves, and gown before you enter the room." Rationale: The worker needs to be informed of the need to wear a mask, gloves, and gown prior to entering the room, how to dispose the equipment when leaving the room, and the importance of handwashing. It would be a violation of client privacy policies to divulge the disease, or how it was contracted, to someone who is not directly involved in the child's care. Telling the worker the child is too sick to watch TV is also a violation of privacy rights.
The practical nurse (PN) is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later, the client reports that the insomnia continues despite following the same routine every night. What action should the PN take first? a. Instruct the client to add a daily routine of regular exercise. b. Determine if the client has been keeping a sleep diary. c. Encourage the client to continue the routine until sleep is achieved. d. Ask the client to describe the current routine practiced by the client.
d. Ask the client to describe the current routine practiced by the client. Rationale: The PN should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information.
Which intervention is most important for the practical nurse (PN) to implement for a client who is experiencing urinary retention? a. Place client's hands in water. b. Apply a skin protectant. c. Encourage increased fluid intake. d. Assess for bladder distention.
d. Assess for bladder distention. Rationale: Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention; therefore, it is vital to assess for bladder distention.
A client receives a prescription for a 5-mg dose of a drug. The oral preparation of this drug is only available as 3 mg/capsule. Which intervention should the practical nurse (PN) implement? a. Administer the prescribed dose of the medication. b. Ask another nurse to check the available drug dose. c. Request a different dose from the pharmacy. d. Call the health care provider about the prescribed dose.
d. Call the health care provider about the prescribed dose. Rationale: Because this drug is only available in oral form as capsules containing 3 mg, the health care provider should be contacted because the prescribed dose cannot be administered.
When performing sterile wound care in the acute care setting, the practical nurse (PN) obtains a bottle of normal saline from the bedside table that is labeled opened and is dated 48 hours before the current date. What is the best action for the PN to take? a. Use the normal saline solution once more and then discard. b. Obtain a new sterile syringe to draw up the labeled saline solution. c. Use the saline solution, then relabel the bottle with the current date. d. Discard the saline solution and obtain a new and unopened bottle.
d. Discard the saline solution and obtain a new and unopened bottle. Rationale: Solutions labeled within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded.
The practical nurse (PN) reinforces information with a client about portion control and diet management. Which portion description indicates that the client understands the instructions? a. A half-cup of ice cream is about the size of a baseball. b. Two tablespoons of peanut butter are about the size of a deck of cards. c. One cup of cooked vegetables is about the size of a racquetball. d. Four small cookies are about the size of four poker chips.
d. Four small cookies are about the size of four poker chips. Rationale: Four small cookies are about the size of four poker chips.
The practical nurse (PN) is assessing the orientation of an older adult client. The client is unable to remember the year and reports being lost and unfamiliar with the surroundings. What documentation is the most accurate for the PN to make? a. Demonstrates loss of remote memory. b. Exhibits expressive dysphasia. c. Has a diminished attention span. d. Is disoriented to time and place.
d. Is disoriented to time and place. Rationale: The client is exhibiting disorientation.
The practical nurse (PN) recognizes which aspect of care has the highest priority for a client with an indwelling urinary catheter? a. Promoting self-care b. Preventing incontinence c. Ensuring hydration d. Preventing infection
d. Preventing infection Rationale: Indwelling urinary catheters are a high source of infection.
A representative of the hospital's accrediting agency is performing an on-site visit at the hospital and asks to see the nurses' notes from a client's medical record. What action should the practical nurse (PN) take? a. Obtain the client's consent for review of the medical record by the representative. b. Delete all identifying client information before providing the requested information. c. Contact the hospital's privacy officer for permission to provide the requested information. d. Provide the agency representative with the information from the client's medical record.
d. Provide the agency representative with the information from the client's medical record. Rationale: A hospital's accreditation agency randomly selects clients and reviews the nursing care documentation to evaluate the standard of care being provided by the hospital. The practical nurse (PN) can provide the agency representative with the requested information.
The practical nurse (PN) is performing nasotracheal suctioning. After the client's trachea is suctioned for 10 seconds, large amounts of thick yellow secretions return. What action should the PN implement next? a. Encourage the client to cough to help loosen secretions. b. Advise the client to increase intake of oral fluids. c. Rotate the suction catheter to obtain any remaining secretions. d. Reoxygenate the client before attempting to suction again.
d. Reoxygenate the client before attempting to suction again. Rationale: Suctioning should not be continued for longer than 10 seconds because the client's oxygenation is compromised during this time.
