Hesi 900 (2nd)
A client is admitted with a hemothorax following a motor vehicle collision, and the surgeon inserts a chest tube that is attached to a chest drainage system with suction at 20 cm water pressure. The practical nurse (PN) observes that the suction chamber fluid level is at 15 cm. Which action should the PN implement to ensure effective functioning of the chest drainage system? A. Additional sterile water should be added to the suction chamber to the 20 cm level. B. Suction at the wall unit should be increased to enhance the velocity of bubbling. C. The chest tube should be irrigated with 20 mL normal saline to ensure patency. D. The tubing should be manipulated until the chest drainage collects in the chamber.
A. Additional sterile water should be added to the suction chamber to the 20 CM level.
A newborn is choking and turning cyanotic with the first sips of sterile water. The healthcare provider prescrites trays and explains that the newborn may have a tracheesophageal fistula (TEF). Which intervention should the pracical nurs (PN) implement until the diagnosis of TEF is confirmed? A. Administer oxygen, suction PRN, and turn the newborn from supine to prone position every 2 hours. B. Offer sterile water per nipple to moisten the oral mucosa then place the infant in a prone position. C. Keep the infant NPO and place in a supine position with the head of the crib elevated 30 degrees. D. Insert an orogastric tube and give feedings via gavage after x-ray
A. Administer oxygen, suction PRN, and turn the newborn from supine to prone position every 2 hours.
When administering carisoprodol, a centrally acting skeletal muscle relaxant, to a client with painful muscle spasms, which action by the practical nurse is most important? A. Advise the client to change positions and stand up slowly. B. Ask the client about any change in normal sleep patterns. C. Instruct the client to report the onset of a headache. D. Encourage the client to rest after self care activities.
A. Advise the client to change positions and stand up slowly
A client receives new prescriptions at 1000 that include discontinuing IV fluids and IV antibiotics. Which prescription should the practical nurse (PN) administer at 1300? A. Ampicillin 500 mg PO q8h. B. Lisinopril 5 mg PO every day. C. Pantoprazole 40 mg PO every day. D. Metformin 1000 mg PO BID.
A. Ampicillin 500 mg PO q8h.
client is receiving nitroglycerin sublingual tablets for angina. Which therapeutic response should the practical nurse (PN) evaluate in the client who takes this drug during an acute anginal episode? A. Cessation of acute chest pain. B. Premature ventricular contractions. C. Hypertension and headache. D. Pulse oximetry within normal limits.
A. Cessation of acute chest pain.
Twenty four hours after receiving a telephone prescription for a client's medication, the practical nurse (PN) observes that the preserption has not been sped the prescriber, which conflicts with agency policy. Which action should the PN take? A. Contact the prescriber for a renewal of the prescription. B. Hold the next dose of medication and assess the client. C. Discontinue the medication immediately. D. Continue to administer the medication as initially prescribed.
A. Contact the prescriber for a renewal of the prescription.
Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the practical nurse (PN) to ask the child? A. Has the child eaten recently? B. When did the child last urinate? C. Did the child perform a fingerstick? D. How much did the child exercise today?
A. Has the child eaten recently?
When preparing to change a client's sterile dressing, the practical nurse (PN) opens a package of gauze pads as seen in the picture. Which action should the PN take next? A. Pick up pads and place on a sterile field. B. Secure the gauze pads over the incision. C. Obtain more dressings from the supply room. D. Apply a new pair of sterile gloves.
A. Pick up pads and place on a sterile field.
The practical nurse (PN) is reassessing the bandage change technique of a clert with s whams reinforcement by the PN? A.Uses spiral turns beginning at distal end. B.Rewraps at intervals to maintain tension. C.Smoothes the bandage when wrapping. D.Holds the bandage roll in the dominant hand.
B.
The practical nurse (PN) is feeding a 2-month-old infant with heart failure (HF) due to a ventricular septal defect (VSD). Which intervention should the PN implement? A. Feed the infant when it cries. B. Allow infant to rest before feeding. C. Insert a nasogastric feeding tube. D. Weigh before and after feeding.
B. Allow infant to rest before feeding.
A hospitalized client had difficulty falling asleep the last two nights and is becoming irritable and restless. Which action by the practical nurse (PN) is best? A. Encourage the client to avoid pain medication during the day, which may increase daytime napping. B. Determine the client's usual bedtime routine and include rituals in the plan of care as safety allows. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 hours to every 8 hours. D. Instruct the unlicensed assistive personnel (UAP) not to wake client under any circumstances during the night.
B. Determine the client's usual bedtime routine and include rituals in the plan of care as safety allows.
The practical nurse (PN) should perform oral suctioning for a client with which problem? A. Dysphasia. B. Dysphagia. C. Gastric reflux. D. Atelectasis.
B. Dysphagia
A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay with the client. B. Escort the client to a calm and quiet place. C. Notify the client's healthcare provider.) D. Administer a PRN medication for agitation.
B. Escort the client to a calm and quiet place.
An older adult client who resides in a long term care facility has a friend of the opposite sex who often visits in the evenings. The practical nurse (PN) enters the client's room to administer medications and finds the couple in bed together. Which action should the PN take? A. Request that the friend get up and leave. B. Exit the room and quietly close the door. C. Report the incident to the family. D. Ask when the nurse should return.
B. Exit the room and quietly close the door ever again. What I'm breaking
For the past six hours, a postoperative client has refused pain medication because the client wanted to "tough it out." When an opioid analgesic is administered, thel client has difficulty obtaining a satisfactory level of comfort. Which action is best for the practical nurse (PN) to use in assisting this client to deal with the pain? A. Turn the television on to the client's favorite show. B. Guide the client through slow, rhythmic breathing. C. Dim the lights in the room and close the door. D. Obtain a prescription for a higher dose of pain medication.
B. Guide the client through slow, rhythmic breathing.
The PN is caring for a primigravida five hours after a vaginal delivery. Which finding should the PN report immediately to the charge nurse? A. Firm fundus between umbilicus and the symphysis pubis. B. Rubra lochia saturating three perineal pads per hour. C. Troubled by perineal pain. D. Heart rate of 90 beats/minute
B. Rubra lochia saturating three perineal pads per hour.
The practical nurse (PN) finds a client who is assigned to another nurse bleeding from an IV site and the IV tubing and fluid are on the floor. The PN immediately applies a dressing to stop the bleeding. Which action should the PN take next? A. Enter computer documentation of the findings and the application of a dressing. B. Tell the nurse assigned to the client about the event so the findings can be recorded. C. Complete the shift documentation for this client and include the findings about the IV. D. Inform the charge nurse that the findings indicate that the client pulled out the IV.
B. Tell the nurse assigned to the client about the event so the findings can be recorded.
The practical nurse (PN) is assigned to care for a team of clients and is delegating tasks to the unlicensed assistive personnel (UAP), Which dient on the Pis team is best for the the UAP to assist with care activities? A. A client with metastatic breast cancer who wants to make funeral arrangements. B. A client with terminal cancer who is receiving a continuous morphine infusion. C. A client with paraplegia who is transferring to a skilled nursing facility tomorrow. D. A newly admitted older adult client who had hip replacement surgery yesterday.
C. A client with paraplegia who is transferring to a skilled nursing facility tomorrow.
A 4-year-old client returned to the day surgery unit after an inguinal herniorrhaphy and has remained stable for the last four hours. The child is taking PO liquids without any nausea, and the parent wants to take the client home. Which finding is most important for the practical nurse (PN) to obtain before discharging the client? A. Testes in the scrotal sac. B. Ambulation tolerance. C. Ability to void. D. Presence of bowel sounds.
C. Ability to void.
The practical nurse (PN) is assisting with the admission of a client with complications of left-sided heart failure. Which focused assessment should the PN implement first? A Heart sounds. B Mood and affect. C Bilateral lung sounds. D Chest pain.
C. Bilateral lung sounds
A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the practical nurse (PN) implement first? A. Offer the client a PRN medication. B. Explain daily schedule of unit activities. C. Describe functions of the practical nurse (PN). D. Review client rights of hospitalization.
C. Describe the functions of the practical nurse (PN).
A client is diagnosed with Clostridium difficile. Which action should the practical nurse (PN) implement to prevent the spread of the organism? A. Keep the door closed to the client's room at all times. B. Wear a particulate respirator mask when in the room. C. Don non sterile gloves when performing direct care. D. Place a surgical mask on the client during transport.
C. Don non sterile gloves when performing direct care.
1. Vital Signs every 4 hours 2. Hydrocodone bitartrate 5 milligrams(mgilacetaminophen 500mg (Vicodini 1 tablet every 6 hours as needed for pain 3. Hydrocodone bitartrate 5 mg/ acetaminophen 500 mg (Vicodin) 2 tablets every 6 hours as needed for pain 4, Hemoglobin & Hematocrit (H & Hi on admission 5. Administer Rubella vaccine if indicated 6. Administer Rho(D) immune globulin (RhoGAM) indicated. Based on the computer documentation in the electronic medical record (ER), which action should the nurse implement? A. Call the nursery for the infant's blood type results. B. Observe the mother breastfeeding her infant. C. Give the rubella vaccine SUBQ. D. Administer hydrocodone/acetaminophen one tablet for pain.
C. Give the rubella vaccine SUBQ.
An older adult client reports having not felt well since returning home from a mission trip to an African village. The complete blood count (CBC) results are red blood cells of 4.2 × 10°/UL (4.2 × 1012/L), white blood cells of 15,000 mm* (15 x 10%/L), neutrophils of 88%, platelets of 300,000 mm* (300 × 10°/L), hemoglobin o 14 g/dL (140 g/L), and a hematocrit of 45% (0.45 volume fraction). The practical nurse (PN) should assess the client for which problem? A. Pancytopenia. B. Immunosuppression. C. Infection. D. Anemia.
C. Infection
The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize? A. Use plenty of pillows to position the client on the side after bathing. B. Report any drainage observed around the GT insertion site. C. Keep the head of the bed raised while the tube feeding is infusing. D. Raise the entire bed while bathing the client to reduce back strain.
C. Keep the head of the bed raised while the tube feeding is infusing.
Which instruction should the practical nurse provide the unlicensed assistive personnel assisting with the care of a client following a lumbar puncture? A. "Report any change in the client's distal circulation checks." B. "It is important to monitor the appearance of the puncture site." C. "Let me know if there is a significant change in the vital signs." D. "Be sure to keep the client supplied with plenty of fluids."
C. Let me know if there is a significant change in the vital signs.
An older adult client is admitted with syncope and laboratory findings indicate a heroglobin of 8.0 g/dL. (80 gL.). The client has a recent history of headaches and frequent falls. Admission prescriptions include continuation of all home medications. Which medication should the practical nurse (PN) withhold until consulting with the charge nurse? Reference range: Hemoglobin (Hgb) [12 to 16 g/dL or 120 to 99 g/L] A. Docusate sodium. B. Aspirin (ASA). C. Levothyroxine. D. Calcium citrate.
C. Levothyroxine
The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. What follow up action(s) should the PN implement Select all that apply. A. Document the appearance of the wound as inflamed. B. Compress the drainage device before closing the tab. C. Remove the drainage device and apply a pressure dressing. D. Report the appearance of the dressing to the charge nurse. E. Clamp the drainage tubing for the next four hours.
C. Remove the drainage device and apply a pressure dressing. D. Report the appearance of the dressing to the charge nurse.
The practical nurse (PN) applies a preparation with keratolytic properties to both legs of a client with psoriasis. Which finding indicates the desired effect has been achieved? A. No purulent drainage present from lesions on the legs. B. Affected areas are free of localized redness and swelling. C. Scaly areas of the skin appear softer with less peeling. D. Full range of motion without pain of lower extremity
C. Scaly areas of the skin appear softer with less peeling.
The practical nurse (PN) observes two unlicensed assistive personnel (UAP) turning an older adult client who had a hip arthroplasty with prosthesis placement four hours ago. Which observation by the PN indicates that the UAPs need additional information about the turning procedure? A. A turning sheet is used under the client for turning and repositioning. B. The UAPs keep their backs straight and knees bent when moving the client. C. The client is told to keep both legs straight and together while turning. D. An abduction pillow is placed between the client's legs when positioned.
C. The client is told to keep both legs straight and together while turning.
The practical nurse (PN) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action? A. The client is lying in a supine position in the bed. B. There is no humidifier attached to the delivery system. C. The flowmeter shows 1 liter of oxygen being delivered. D. The cannula is pressed snugly against the client's cheeks.
C. The flowmeter shows 1 liter of oxygen being delivered
The parent of an 8-year-old client tells the practical nurse (PN) that the child fell out of a tree and hurt the arm and shoulder. Which assessment finding should the practical nurse (PN) note as the most significant indicator of possible child abuse? A. The child cries while treatment is applied to multiple abrasions. B. The parent refuses to answer questions about family history. C. The story of the injury given by the parent differs from the child's. D. The nurse observes the child looking down when answering questions.
C. The story of the injury given by the parent differs from the child's.
A client who is a primigravida tells the practical nurse (PN), "My baby seems to be sleeping, but look at the funny movements he is making." The PN notices that the infant is making hand-to-hand movements, smacking his lips, and turning his head. Which is the best response for the PN to make? A. Check to see if the infant needs a diaper change. B. Allow the infant to sleep. The baby is probably only dreaming. C. These movements indicate that the infant is hungry. D. The infant may be uncomfortable. Place the infant on its side.
C. These movements indicate that the infant is hungry.
The practical nurse (PN) is caring for a client newly diagnosed with diabetes mellitus (DM). Which finding is an early sign of hypoglycemia? A. Difficulty swallowing. B. Polyuria. C. Tremors. D. Bradycardia.
C. Tremors
The practical nurse (PN) is reinforcing discharge information provided to a client who recelved an intraocular lens implant. Which client corn additional teaching is necessary? A Prescription glasses may still be required following surgery. B Light activity, such as walking and reading, are permitted. C Driving a motor vehicle can resume a week after discharge. D A metal eye shield should be worn at night while sleeping.
D.
After administering pantoprazole to a client with gastrosophageal reflux disorder (GERD), which statement by the client indicates to the practical nurse (PN) that the medication is producing the desired effect? A. "I am able to swallow all the food on my tray without difficulty." B. "I no longer need to strain to have a bowel movement." C. "I have a great appetite and am feeling really hungry." D. "I did not experience any heartburn after eating lunch."
D. "I did not experience any heartburn after eating lunch."
The practical nurse (PN) is making a home visit to an older adult client who was recently diagnosed with Herpes zostar. The dient reports the orset of sever burning pain along the right side of the trunk. Which action should the PN take? A. Notify the nursing supervisor of the uncontrolled pain. B. Give the next prescribed dose of antiviral medication. C. Obtain and oxygen tank for home administration. D. Administer a prescribed PRN dose of analgesic.
D. Administer a prescribed PRN and dose of analgesic.
A clear liquid diet is prescribed the first postoperative day for a client who had an abdominal hysterectomy. What choice(s) should the practical nurse (PN) provide for this client? Select all that apply. A. Chocolate milkshake and custard pudding. B. Cream of chicken soup and milk. C. Vanilla ice cream and pureed peaches. D. Clear carbonated drinks and apple juice. E. Popsicle and beef bouillon broth.
D. Clear, carbonated drinks, and apple juice. E. Popsicle and beef bouillon broth.
The practical nurse (PN) accompanies a healthcare provider when the client receives the diagnosis of stage 5 metastatic cancer. The client's spouse immediately responds, "You must have made a mistake. We want to get a second opinion." The PN should consider which stage of the grieving process in order to respond best to the spouse's comments? A. Intellectualization. B. Conversion reaction. C. Bargaining. D. Denial.
D. Denial
The practical nurse (PN) observes a clients eyes and identifies the presence of unilateral eyelid drooping that was not present during the previous assessment. Which follow-up evaluation by the PN is most important? A. Measure visual acuity. B. Test skin elasticity. C. Observe the color of the sclerae. D. Determine level of consciousness.
D. Determine level of consciousness
What is the first intervention for the practical nurse (PN) to implement when a client refuses to take a prescribed medication? A. Explain to the client the potential harm in not taking the medication. B. Instruct the client about the purpose of the medication. C. Document the client's refusal on the medication record. D. Determine the client's reason for refusing the medication.
D. Determine the client's reason for refusing the medication.
A client with bipolar disorder reports to the practical nurse (PN) of not having taken a prescribed important for the PN to obtain? medication, divalproex sodium, for the last 6 months. Assessment of which parameter is most important for the PN to obtain? A. Hyperactivity. B. Headache pain. C. Speech pattern. D. Frame of mind.
D. Frame of mind
The practical nurse (PN) is working with a newly hired PN on a medical surgical unit. Which action performed by the newly hired PN requires intervention by the PN? A. Providing healthcare Information by report to the client's physical therapist. B. Posting client names and healthcare providers on hospital room doors. C. Requesting clients to sign their name on a roster at the front desk. D. Informing clergy that a church member has been admitted to the facility.
D. Informing clergy that the church member has been admitted to the facility.
The practical nurse (PN) is assisting a client who is multiparous in active labor with breathing techniques during contractions. The client's contractions are first occurring every 2 minutes, with a duration of 80 seconds, when she suddenly wants to go to the bathroom to have a bowel movement. Which should the PN do? A. Provide the client with a bedpan to have a bowel movement. B. Obtain fetal heart rate and maternal vital signs. C. Instruct the client to push with each contraction. D. Notify the registered nurse (RN) of the client's urge to push.
D. Notify the registered nurse (RN) of the clients urge to push.
A client tells the practical nurse (PN) that he is afraid of getting cancer so he plans to quit smoking cigarettes by switching to a smokeless tobacco product. How should the PN respond? A. Explain to the client that obesity is a more significant health risk than smoking. B. Remind the client that it is likely the client gain weight when attempting to stop smoking. C. Encourage the client to continue with this plan to reduce the risk for cancer. D. Provide information to the client about risks associated with smokeless tobacco.
D. Provide information to the client about risks associated with smokeless tobacco.
A client who is receiving a statin medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN takes priority? A. Administer a PRN dose of acetaminophen. B. Encourage the client to drink fluids. C. Monitor the client's serum lipid levels. D. Report the findings to the charge nurse.
D. Report the findings to the charge nurse.
A client who is being cared for in home has a low serum sodium level of 125 mEq/L. (125 mmol/L). To determine the cause of this value, which information stol the practical nurse (PN) request from the client? Reference range : Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] A. The amount of ice chips and water consumed daily. B. The percent of processed or canned foods eaten. C. The number of vegetable servings consumed daily. D. The amount of salt substitute used in meal preparation.
D. The amount of salt substitute used in meal preparation.
A client with a chronic medical condition tells the practical nurse (PN) that he wants no heroics to prolong his life if anything should happen to him. Which action should the PN take? A. Complete an advance directive form and place it in the medical record. B. Notify the client's healthcare provider of the client's wishes as soon as possible. C. Place a "Do Not Resuscitate" sign outside the client's door and at the bedside. D. Reassure the client that life saving measures will not be taken without consent.
X
After change-of-shift report, the practical nurse (PN) makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the PN? A. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal. B. A client who has pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy. C. A client who has brown green bile draining from a T-tube after a cholecystectomy for cholelithiasis. D. An older client whose blood pressure is 100/70 mm Hg after receiving meperidine for pain related to a hip fracture.
X
The practical nurse (PN) notes that an older adult client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are recorded as an oral temperature of 99.8° F (37.66* C), a heart rate of 94 beats/minute, respirations of 22 breaths/minute, and a blood pressure of 108/54 mm Hg. Which intervention is most important for the PN to implement? A. Provide care to moisten oral mucosa. B. Report the findings to the charge nurse. C. Offer the client fluids frequently. D. Monitor the client's temperature hourly.
X
Tuberculosis (TB) screening at a federal prison reveals that two inmates have a positive skin test. Which action is most important for the practical nurse (PN) to take? A. Validate initial screening of staff is completed. B. Recognize antitubercular medications are needed. C. Complete data entry for chest x-ray (CXR) referrals. D. Plan for rescreening of population in 6 weeks.
X
The practical nurse (PN) notices that a client's urine is pale yellow, with a cloudy appearance, and has a foul odor. Which assessment should the PN complete next? A. Assess skin appearance and elasticity. B. Palpate the bladder area for distention. C. Ask the client about urinary frequency. D. Observe the feet and legs for swelling.
B. Palpate the bladder area for distention.
After administering the client's 0730 prescribed dose of regular insulin per a sliding scale, which action by the practical nurse has the highest priority? A. Observe the client for pallor, diaphoresis, or fatigue. B. Notify the charge nurse of the dose of insulin administered. C. Measure the client's vital signs and oxygen saturation. D. Instruct the unlicensed assistive personnel (UAP) to take the client a breakfast tray.
A.
The practical nurse (PN) should recognize that immunosuppressed clients are likely to exhibit which symptom during the initial stage of the disease? A. A persistent common cold. B. Enlarged spleen. C. Weight loss. D. Decreased blood pressure.
A. A persistent common cold
The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.) = A 10-year-old child with bleeding lacerations on both knees after falling on the playground. = A 12-year-old child with history of asthma who is wheezing and troubled by shortness of breath. = A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode. = A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.
- 12 year old -7 year old -10 year old - 5 year old
The practical nurse is prepared to insert an older clients bilateral hearing aids. After determining which ear mold is for the right, and left ear and checking the batteries to be sure they are working properly, in which order should the PN implement these actions? (Place the first action on top and the la checking the batteries to be sure they are working properly, in which order should the PN implement these actions? (Place the first action on top and the last action on the bottom.) = Gently press ear mold into ear while rotating backward. = Turn hearing aid on and adjust the volume for the client. = Line up the ear mold with the client's external auditory opening. = Turn the hearing aid off and set the volume at low. = Rotate the ear mold slightly forward and insert in the ear canal.
-Turn the hearing aid off and set the volume at low. -Line up the ear mold with the clients external auditory opening. -Rotate the ear, mold slightly flow and insert in the ear canal. -Gently press emerald into air rotating backward. -Turn hearing aid on and adjust the volume for the client.
Several residents of a long term care facility are receiving eye drops to treat glaucoma. The practical nurse (PN) should caution the unlicensed assistive personnel (UAPs) caring for these clients to observe for which effect because it places the clients at risk for falls? A. Elevated bland pressure. B. Pupillary constriction. C. Increased heart rate. D. Conjunctival redness.
A Elevated bland pressure.
The practical nurse (PN) is monitoring a client's neurologic status following a closed head injury. What assessments) should the PN include? Select all that apply. A Pupillary reactions. B Consciousness level. C Jugular vein distention. D Vital sign measurement. E Carotid pulse rate.
A Pupillary reactions. B Consciousness Level D. Vital sign measurement
The practical nurse (PN) is assisting the nurse with the admission physical assessment of a client diagnosed with pneumonia. What symptom(s) is the client most likely to exhibit? Select all apply. A Lung crackles. B Ankle edema. C Bradycardia. D Dyspnea. E Painful cough.
A. Lung crackles. C. Bradycardia. D. Dyspnea
What finding(s) can the practical nurse (PN) determine by palpating a client's skin? Select all that apply- A. Perspiration. B. Cyanosis. C. Itching. D. Pallor. E. Warmth.
A. Perspiration. E. Warmth.
Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis? A Weigh the child daily. B Encourage fluid intake. C Administer vitamin supplements. D Promote complete bed rest.
A. Weight the child daily
A client with cholelithiasis is choosing the evening meal. Which dessert is best for the practical nurse (PN) to recommend to this client? A. Ice cream. B. Cookies. C. Banana cream pie. D. Cake with whipped cream icing.
B. Cookies
The practical nurse (PN) is caring for a 17-year-old client who fell 20 feet while climbing the side of a cliff and has been in a sustained vegetative state for 5 months since the accident. Which intervention should the PN implement? A. Inquire about food allergies and food likes and dislikes. B. Talk directly to the adolescent while providing care. C. Initiate open communication with the teens parents. D. Monitor vital signs and neurological status every 2 hours.
B. Talk directly to the adolescent while providing care.
A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement? A. Document abdominal girth. B. Weigh every morning. C. Perform range of motion exercises. D. Use a cushion when sitting.
B. Weight every morning.
The practical nurse (PN) turns a client with right sided paralysis from a supine to a left lateral position. Which bony prominence is most likely to manifest signs of erythema when first turned? A. Ischial tuberosities. B. Iliac crest. C. Sacrum. D. Lateral malleolus.
C. Sacrum
The home health practical nurse (PN) visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who provide care for the client, state that their son sleeps most of the time. The PN observes the client is semi-conscious with stable vital signs and cries out in pain when tumed or moved. A fentanyl patch is in place and skin lesions are closed and dired. Which intervention should the PN implement? A. Give a complete bed bath to further assess the client. B. Discuss end-of-life decisions with the client's parents. C. Call for ambulance transportation to the hospital immediately. D. Remove the fentanyl patch as directed by prescription.
Cause
A client is diagnosed with a seizure disorder and is completing testing before discharge from the healthcare facility. What information should the practical nurse (PN) reinforce to avoid the incidence of seizure episodes? Select all that apply. A Carry phone number of Epilepsy Foundation at all times. B Stay well rested and avoid a large caffeine intake. C Avoid flashing lights and excessive visual stimuli. D Seek a safe place if sensing dizziness or sensory disturbances. E Generic medications are safe to substitute for trade name brands.
X
A client who is admitted to the hospital with depression is escorted in a private room. prior leaving the room, which intervention is most important for the PN to implement? A. Review the healthcare provider's prescriptions. B. Initiate psychosocial assessment. C. Search all personal belongings. D. Explain the program guidelines.
X
An older adult female resident of a long-term care facility experiences frequent episodes of urinary incontinence. Which focused assessment is most important for the practical nurse (PN) to perform regularly in response to the resident's incontinence? A.Fluctuations in the body weight. B. Ability to perform Kegel exercises. C. Appearance of skin in perineal area. D. Sleep and rest patterns and routines.
X
