HESI FUNDAMENTALS ASSIGNMENT EXAM 3

Which finding should the practical nurse report to the healthcare provider prior to administering as IV solution with added potassium chloride?

urine output of 120 ml in 8 hours

When providing perineal care for an uncircumcised male client, the PN should implement which action?

retract the foreskin before cleansing the glans and replace the foreskin after the procedure.

Which factors influence how the practical nurse obtains vital signs on a client. Select all that apply.

-history of right radical mastectomy two years ago -daily use of oral digoxin -client height of 5 feet 6 inches, weight 240 pounds.

The practical nurse notifies the healthcare provider that a male client has become combative and needs a protective device to prevent injury to self and others. Which principle should the PN use in selecting a protective device?

a protective device provides the least amount of immobilization.

The practical nurse is giving iron dextran 250 mg IM using the Z track method to a client with anemia.Which needle should the PN select for this injection?

2 inch, 19 gauge

The practical nurse is calculating a 6 hour intake for a postoperative client. Based on the clients bedside record, how many mL of intake should the PN enter in the clients record? (Enter numeric value only). one cup of coffee, one 8 oz glass of ice tea, one 6 oz dish of flavored gelatin, one half cup of chicken broth.

750 mL.

Which client needs immediate action by the practical nurse

An older client who is climbing over the side rails.

The practical nurse is documenting the administration of a client's medication. Which entry by the PN complies with joint commissions guidelines for use of abbreviations?

Doses of clonidine 0.15 mg given AC BID.

A client with a forearm laceration arrives in the clinic applying direct pressure with a clean washcloth. The PN notes that the washcloth is saturated with blood. What action should the PN implement?

apply digital pressure to arm above the injury

An older client is receiving normal saline at 83 ml/hour per gravity. At the end of shift assessments, the PN calculates the clients intake and output and determines that the infusion delivered 500 ml in the last hour. Which action should the PN take first?

ascultate the lungs for crackles

Which intervention is most important for the practical nurse to implement to decrease the number of falls for clients in a long term care facility?

ask about the need to use bathroom

A client who had abdominal surgery yesterday is receiving morphine via a PCA. The client reports a pain level of 6 based on a scale of 1-10. What actions should the PN implement first?

ask for a description of the pain

A male client who walks in the clinic begins talking to the practical nurse with slurred speech. which action should the PN implement first?

ask the client how he's feeling today

The practical nurse is assigned the PM care of six clients on a medical surgical unit whose morning laboratory results are not available. What action should the PN take?

call the lab to ask if the client's test results are ready

The healthcare provider prescribes wrist restraints for a client who is agitated and combative. Which action should the PN implement?

check the clients skin color, warmth, and pulses distal to the restraining device.

The PN is reviewing the MAR for a client who receives warfarin daily. A notation on the MAR yesterday is marked "hold" for the daily Coumadin dose and no other directs are noted for today's dose. What action should the PN take?

check the prescription

The PN is caring for an older client who is receiving oxygen 4L per nasal cannula. Which finding indicates a therapeutic response?

client oriented to time and place.

The pracitcal nurse is collecting data from clients electronic medical records for the nurse manager's quality assurance review about documentation of client pain relief. What information should the PN include as the best measure of pain relief?

client pain intensity documented 1 hour after analgesia

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

clients with headaches

The practical nurse is reviewing the schedule of yearly inservice programs for competency-based nursing care. Which criteria should the PN use in selecting programs that provide the best content to maintain nursing competency?

complex procedures that are done only a few times a month.

The practical nurse hears an auscultatory gap in the Korotkoff sounds of an older client with hypertension. What action should the PN implement when obtaining the client's blood pressure?

continue to listen for the next Korotkoff sound until the cuff is deflated.

The practical nurse is working with a newly employed PN who is having difficulty preparing the infusion pump for the administration of an IV medication per secondary infusion. What action should the PN implement?

demonstrate the use of the IV pump.

A client who is three days postoperative complains of having "really bad pain" and wants medication now. What action should the practical nurse implement?

determine the location of the pain

The practical nurse is obtaining a blood specimen from a client's peripherally inserted central catheter. What action should the PN take first?

discard first 5 ml of blood sample

The family of a male client with terminal cancer decides not to tell the client about his prognosis. The client has asked the PN several times if he is dying. What action should the PN implement>

discuss the client's frequent questions with family and healthcare provider.

Which technique is most important for the practical nurse to implement when obtaining a specimen for urinalysis, culture, and sensitivity for a male client?

ensure client understands to retract the foreskin and cleanse meatus

Which intervention should the PN implement for a client who is scheduled for a lumbar puncture?

ensure the client's bed is positioned flat

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

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

A client is receiving supplemental oxygen. The practical nurse walks in the room and sees a fire in the bedside wastebasket. Which action should the PN take first?

take client out of the room

At 0900, a client's blood pressure is 120/70. At noon, the unlicensed assisitive personnel reports that the client's blood pressure is 200/100. Which action should the PN implement first?

take clients blood pressure

The practical nurse is administering eye drops to a client with glaucoma. Which technique should the PN implement to ensure the eye drops are effectively absorbed topically?

tell the client to move closed eyes from side to side

The practical nurse uses the SBAR format to report an acute client situation to the healthcare provider. Which information is the correct understanding of this method?

the R stands for recommendation and suggests an action for the healthcare provider.

The practical nurse is assisting the nurse in the administration of a unit of blood to a client with AB+ blood type. Which finding should the PN identify as a policy standard that should be addressed first

the client does not have an identification bracelet

A client who has a tunneled Hickman catheter for hemodialysis receives a prescription for IV an antibiotic. Which action should the practical nurse take?

utilize a peripheral IV access to administer IV antibiotics

The practical nurse is preparing to give a complete bed bath to an unconscious client. After implementing standard precautions before the procedure, which action should the PN implement next?

wash each eye with a fresh area of a washcloth before washing the rest of the face

A client with a possible mumps infection is admitted to an acute care facility. Which infection control precaution should the PN implement

wear a mask or respirator within 3 feet of the client.

An older client arrives a the outpatient clinic complaining of burning and severe right sided chest pain. The pN observes vesicular eruptions in a line across the anterior and posterior chest wall. What action should the PN implement?

wear gloves during palpation

A client with Clostridium difficile is placed on isolation precautions. Which transmission based precaution should the practical nurse implement?

wear gown and gloves when rendering direct care.

When determining if the client is compliant with a prescribed medication regimen, which question is best for the practical nurse to ask?

when and where do you take this pill at home?

The practical nurse is obtaining blood specimens from a client. After inserving the needle into the arm, the client screams and reports an electric shooting pain in the arm. What actions should the PN implement?

withdraw the needle from the arm

Which disposable product should the practical nurse place in a biohazard container?

Peri-pads saturated with rubra lochia for a client who is one day post-vaginal delivery.

An UAP tells the PN that another nurse on the unit is acting disrespectfully. What action should the PN implement?

Tell the UAP to share feelings with the nurse

The practical nurse is caring for a client who being to vomit copious amounts of blood. What action should the PN do first?

Use a Yankauer tip device for oropharyngeal suction.

Which action by another nurse should the practical nurse report as a breach of client confidentiality?

Visitors are told to wear a mask because the client has tuberculosis

The practical nurse is administering medications to several clients. Which client requires immediate action by the PN?

a male client who states that his throat feels tight.

The practical nurse is reinforcing self care with a male client who is being discharged with an ileostomy. Which client behavior best indicates to the PN that he understands iliostomy care?

empties the ileostomy appliance bag when it is about one third full.

Which action should the practical nurse take for a client whose serum sodium level is 159 mEq/L

encourage fluid intake of 2500 mL. daily.

The wife of an older, overweight man tells the PN that her husband snores and frequently wakes up jerking or gasping. What action should the PN take?

discuss the possibility of a sleep study for sleep apnea

The practical nurse is reviewing discharge information with a client who is positive for HIV. Which action should the PN reinforce with prevention of transmission of HIV?

disinfect areas contaminated with body fluids using 1:10 bleach solution.

A client who is 8 hours postoperative begins using the incentive spirometer with 750 ml inspiratory volume and coughs up a large thick light yellow white mucous plug. What action should the practical nurse take

document the findings

A client who is postoperative is receiving an infusion at 80 mL/hour. At the end of 8 postoperative hours, the PN documents that the client tolerated 100 mL oral intake of ice chips and urinary output is 1100 mL. What action should the PN take

document the intake and output findings.

The practical nurse is caring for a male client who wears a hearing aid. Which client behavior should the PN identify that indicates further evaluation of the clients ability to hear?

does not respond when his name is called from behind

The practical nurse is preparing to change the abdominal dressing for a client who had abdominal surgery yesterday. When should the PN reinforce teaching about the clients dressing change?

during the dressing change

when should the practical nurse reinforce teaching to a client about a daily surgical dressing change.

during the next dressing change.

What finding should the practical nurse document to describe infiltration at a client's IV site?

edema and cool skin at insertion site

A male client with coffee ground emesis is admitted with a hemoglobin of 10.2 grams that is now 7.5 grams/dl since admission. The client's blood is type and crossmatched for two units of blood, and the healthcare provider prescribes STAT administration of one unit. The client indicates to the PN that he wants to shower first. Which intervention should the PN implement?

explain the need for starting the transfusion immediately.

The practical nursie is preparing to transfer a male client from the telemetry unit to an unmonitored medical surgical unit. Which action should the PN take first?

give report to receiving nurse

The practical nurse stops to help at a serious motor vehicle collision site and applies pressure to one of the victims neck that is spurting blood. The client subsequently dies. Which legal concept applies to the PN's actions

good samaritan

For several days after her husband's death, a client who is admitted with acute depression repeats over and over, "I should have made him go to the doctor when he said he didn't feel well. Which descriptor should the practical nurse use to document the client's feelings?

guilt

The practical nurse is providing skin care to an older male client who has the tendency to stay on his left side in a lying position. Which body prominence should the PN identify as the site most likely to develop alterations in skin integrity?

ilium

A client is admitted with bacterial meningitis. Which intervention is most important for the PN?

implement droplet precautions.

The practical nurse identifies four assigned clients that need additional follow-up care. Which client issue has the highest priority?

infiltrated intravenous secondary medication

The practical nurse is planning morning care for a client with GI bleeding and a hemoglobin level of 8.1 grams/dl who is scheduled to receive a unit of packed red blood cells. What should the practical nurse take?

initiate serial signs vital signs before and during the transfusion.

The practical nurse is checking client care equipment in the clinic for proper functionality. Which finding should the PN identify as a piece of equipment in need of repair

intravenous pump alarms constantly

Which equipment malfunction should the practical nurse report as having the highest risk to client safety>

intravenous pump screen does not light up when turned on

The practical nurse obtains an irregular pulse rate of 102 bpm for a client with a history of cardiac disease. Which action is most important for the PN to implement?

listen to the apical rate for one full minute

A client has an automatic blood pressure cuff on the right arm where an IV is infusing. In the left arm, a saline lock is present. The PN notes the presence of blood in the IV infusion line. What action should the PN implement?

move the blood pressure cuff to the left arm

The practical nurse finds an older female client lying on the floor. What action should the PN take first?

obtain the client's vital signs

Which action should the PN implement to minimize the risk of hypernatremia for an older client?

offer fluids on a set schedule throughout the day.

A client who is two days postoperative for a colectomy and temporary colostomy tells the PN that the drainage bag is full of gas. What action should the PN take?

open the bag's clamp to release the flatus

A client presents to the emergent care center reporting chest pain and feeling "lightheaded" as if he is "going to faint." What is the most important action the PN should implement?

place client in a chair or upright on a stretcher

The practical nurse is assessing a client and obtains a pulse rate of 120 beats/minute, respiration of 28 breaths/minutes and a blood pressure of 80/60. What action should the PN take first?

position the client flat in the bed.

The healthcare provider prescribes an immediate transfer to the intensive care unit for a client who has become unstable. Which action is most important for the practical nurse to implement?

provide a SBAR report of the client's status to the charge nurse

The practical nurse is administering otic drops to an adult client with otitis externa. Which action describes the correct administration technique?

pull the pinna of the ear up and out

A client's serum potassium level is 2.9 mEq/L. Which is the most important finding that the PN should report to the charge nurse?

pulse rate weak and irregular

Which finding indicates to the practical nurse that the client is meeting the rehabilitation goals after an acute brain attack?

puts hands on chair arms when standing to use a walker

A client who is demonstrating violent behavior is restrained by personnel using a 4 man maneuver. Two days later, the practice nurse sees that the clients arm is ecchimotic and mottled. What finding is most important for the PN to document.

radial pulse

The healthcare provider calls the nurses' station to give telephone call prescriptions for a client who is recently aditted to the unit. The practical nurse is unsure of the prescription given by the healthcare provider. Which action should the PN take?

read back the prescription to the healthcare provider

The practical nurse is preparing to reinforce information with a client who has chronic pain. Which learning objective should the PN review?

recalls two nonpharmacological interventions used to relieve pain.

A client who is placed in wrist protective devices begins to complain of pain and swelling in one hand. That PN notes that both hands are cool and pale. Which action should the PN take?

remove both devices and notify the healthcare provider.

The healthcare provider prescribes a vest restraint for an older male resident in a long term facility who frequently falls out of his wheelchair. Which action should the PN implement?

remove device every 2 hours and change client's position.