Fundamentals HESI
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.)
125 mcg × 1 mg/1000 mcg × 1 tablet/0.25 mg = 0.5 tablet
An elderly client who attends an adult day care program and is wheelchair-mobile has redness in the sacral. 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. The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers.
Which client finding requires further action by the practical nurse (PN)?
A disoriented client's soft wrist restraints are tied to the bed frame. BThe drainage tube of an indwelling catheter is looped below the client's bladder.CThe aspirant of a client's nasogastric tube has a pH of 4.DSkin over the coccyx blanches when the client is repositioned to a lateral position. 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.
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. B C. C D. D 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 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. 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) reinforces information with a client about portion control and diet management. Which portion description indicates that the client understands the instructions?
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. Four small cookies are about the size of four poker chips.
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 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.
When reading a prescription, what should the practical nurse (PN) verify in addition to the "five rights" of medication administration?
A.Anticipated adverse effects B.Required client teaching C.Client's allergies D.Prescriber's signature
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. 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 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
The practical nurse (PN) is assessing a client's 2 days status/posthip 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
An elderly 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 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. 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's plan of care includes a nursing diagnosis of "Altered sleep patterns related 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. Decreasing intake of fluids during the evening is helpful to decrease nocturia.
The practical nurse (PN) is assessing the orientation of an elderly 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
The practical nurse (PN) is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. What action should the PN take next?
A.Document that the client responded to a painful stimulus. B.Observe the clientʼs response to verbal stimulation. C.Place the client on seizure precautions for 24 hours. D.Report decorticate posturing to the health care provider. The client has demonstrated a purposeful response to pain, which should be documented as such.
The practical nurse (PN) is performing nasotracheal suctioning. After the client's trachea is suctioned for 15 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. Suctioning should not be continued for longer than 10 to 15 seconds because the client's oxygenation is compromised during this time.
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. 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.
The practical nurse (PN) is observing a new unlicensed assistive personnel (UAP) perform indwelling catheter care for a female client who is incontinent of feces. What action should the PN suggest the UAP to change?
A.Frequently rinses the washcloth used to clean the perineum B.Wipes the perineum from front to back C.Applies a skin barrier ointment to irritated perianal areas D.Places the client in a lateral Sims position with the opposite bed rails elevated Even though the washcloth is rinsed frequently, it remains contaminated with fecal materials, and the PN should recommend the use of disposable wipes or separate washcloths, which are less likely to bring fecal flora to the urethral opening
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 liters per nasal cannula. B.Raise the head of the bed. C.Observe for tracheal deviation. D.Reassure and stay with the client. Raising the head of the bed facilitates respiratory functioning. The first action is that client should be placed in a semi-Fowler or Fowler 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) is instructing a client in the proper use of a metered-dose inhaler. Which instructions should the PN reinforce to the client to ensure the optimal benefits from the drug?
A.Inhale and then compress the inhaler. B.Compress the inhaler while slowly breathing in through the mouth. C.Compress the inhaler while inhaling quickly through the nose. D.Exhale completely after compressing the inhaler and then inhale
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. 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 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. Gloved hands held below waist level are considered unsterile.
An elderly client calls the clinic reporting weakness and dizziness. Further assessment by the practical nurse (PN) indicates that the client self-administered an enema of 3 liters 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 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.
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. :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 spouse of a client with terminal cancer provided the practical nurse (PN) with a copy of the client's living will. What action should the PN take?
A.Place a certified copy of the living will in the client's chart. B.Notify the health care provider of the client's wishes. C.Alert the nursing staff of the client's "do not resuscitate" (DNR) status. D.Facilitate a family meeting with the palliative care team. The health care provider needs to be informed of the clientʼs wishes and a prescription written to specify how the staff should respond to medical emergencies. A copy should be placed on the chart, but it does not need to be a certified copy. A living will does not necessarily indicate DNR status. The client and the clientʼs family should be informed about palliative care, but a meeting with the team should be facilitated only at their request.
Which intervention is most important for the practical nurse (PN) to implement for a client who is experiencing urinary retention?
A.Placing client's hands in water. B.Apply a skin protectant. C.Encourage increased fluid intake. D.Assess for bladder distention. 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.
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. 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.
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. The saline flows by gravity and should be held about 12 inches above the bod
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. The saline flows by gravity and should be held about 12 inches above the body.
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. 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. Stimulates skeletal muscle contraction that promotes venous return and helps prevent syncope or injury.
The practical nurse (PN) determines that a client's radial pulse is irregular. What action should the PN take next?
A.Record the client's pulse rate and irregular rhythm. B.Review the client's 12-lead ECG report in the medical record. C.Take an apical pulse for 1 minute to verify irregularity. D.Report the finding to the health care provider
Following an open reduction of a fractured femur, a client is placed in skeletal traction. Based on the nursing diagnosis of "Potential impairment of skin integrity related to immobility," which nursing intervention should the practical nurse (PN) implement?
A.Release the traction, turn the client, and give back care. B.Turn the client while someone lifts the traction weights and give back care C.Lubricate the hands, slide them under the client, and give back care. D.Give back care after the client is released from traction.
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 with soap and water as needed. D.Secure with gauze if client has allergy to adhesives. E.Apply lotion before attaching the probe Site rotation, skin cleansing, and avoidance of adhesives for allergies should help prevent skin irritation or breakdown.
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.Thirty to 60 minutes after administration of an analgesic 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.
Which nursing diagnosis has the highest priority that the practical nurse (PN) should identify when planning care for a client with an indwelling urinary catheter?
A.Self-care deficit B.Functional incontinence C.Fluid volume deficit D.High risk for infection Indwelling urinary catheters are a high source of infection.
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.
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.Simʼs with a pillow under the upper leg. C.Fowler's with both legs supported. D.Any position that is comfortable. In the Fowler 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 several clients before surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?
A.Taking birth control pills for the past 2 years B.Taking anticoagulants for the past year C.Has recently completed antibiotic therapy D.Has taken laxatives PRN for the last 6 months Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for developing surgical complications. The health care provider should be informed that the client is taking such drugs.
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.
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.
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 Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning
A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the practical nurse (PN)?
A.White blood count of 10,000 mm3 B.Serum glucose of 115 mg/dL C.Purulent sputum D.Excessive hunger Steroids cause immunosuppression, and purulent sputum is an indication of infection, so this symptom is of greatest concern.
The practical nurse (PN) is assisting with bathing an independent adult client who has a plaster cast on the right forearm. Which action should the PN implement to encourage self-care by the client?
A.Wrap the client's cast in a plastic bag. B.Move the client to the bathroom sink. C.Provide back care and foot care as needed. D.Give oral hygiene and perineal care. The PN should provide back care, foot care, and other assistance as needed by the client, but the client's independence should be encouraged and his privacy respected.
A client receives a prescription for a 5-mg dose of a drug. The oral preparation of this drug is available as 3 mg/capsule. Which intervention should the practical nurse (PN) implement?
A.dminister 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. 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.
While morning care is being provided, a client becomes restless, agitated, and confused. The client's heart rate is elevated, and respiratory rate is 24 breaths/min. Which additional finding should the practical nurse (PN) identify as an early sign of hypoxia?
APeripheral cyanosis B.Oral temperature of 100.4° F C.Shallow respirations D.Elevated blood pressure The blood pressure becomes elevated during the early stages of hypoxia in an effort to increase perfusion to distal tissues. Respiratory changes related to hypoxia are increased rate and depth of respiration.
The practical nurse (PN) is assisting a client to ambulate with a cane.
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.
