Exit Hesi Practice Questions

A client confides to the PN that the client has been substituting herbal supplements for high blood pressure instead of the prescribed medication. How should the PN respond first? A. Ask the client's reason for choosing to take herbs instead of prescribed drugs B. Reinforce that the healthcare provider prescribed the medication for a reason C. Have client use own words to describe complications of high blood pressure D. Point out the risks of not taking the herbal medications rather than prescribed

A

A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal? A. Emphasize the importance of active foot flexion B. Check the surgical dressing C. Complete an incident report D. Explain the use of incentive spirometer q2 hours

A

A male client attends a community support program for mentally impaired and chemical abusing clients. The client tells the PN that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client? A. Hypertension B. Hepatitis C. Glaucoma D. Diabetes

A

A new mother who is breastfeeding her newborn for the first time after delivery reports nipple pain when the baby sucks. Based on this client problem, which action should the PN take? A. Ensure that all the areolar tissue of the nipple is in the infant's mouth B. Have the mother reposition the infant from the cradle to the football hold C. Check for engorgement and check the nipples for cracks or lesions D. Apply an ice pack to the breast for 10 minutes before each testing

A

A young adult male tells the PN he has decided to change his hours at work so that he has more time to devote to his community. Which stage of Maslow's development is this young adult attempting to achieve? A. Self-Actualization B. Intimacy vs. Isolation C. Altruism D. Purposefullness

A

After administering pantoprazole to a client with gastroesophogeal reflux disorder(GERD), which statement by the client indicates to the practical nurse that the medication is producing the desired effect? A. After eating my meal, I did not experience any heartburn B. I have a great appetite and am feeling really hungry C. I should increase the amount of vitamin C in my diet D. While eating, I had no difficulty swallowing any of the foods

A

Based on the computer documentation in the EMR, which action should the PN implement? A. Give the rubella vaccine subcutaneously B. Observe the mother breastfeeding her infant C. Call the nursery for the infant's blood type results D. Administer hydrocodone/acetaminophen one tablet for pain

A

During a clinic visit for a sore throat, a client's basal metabolic panel reveals a serum potassium of 3.0 mEq/L. Which intervention should the PN recommend to the client based on this finding? A. Increase intake of dried peaches and apricots B. Reduce intake of red meats C. Encourage use of soft toothbrush D. Force fluid intake to 1500 mL daily

A

During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed and refuses to participate in planned daytime activities. Which action should the practical nurse take? A. Record the findings and report the symptoms to the charge nurse B. Ask the family members to visit more often to stimulate the patient C. Motivate the client by offering favorite foods as a prize D. Withold any medications that may cause side effects

A

The PN and UAP enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first? A. Obtain emergency help B. Feel for a carotid pulse C. Bring a glucometer to the room D. Check the blood pressure

A

The PN notes that an UAP is ambulating a male client who had a stroke and has right-sided weakness. The UAP is walking on the client's left side. Which action should the PN take? A. Instruct the UAP to walk on the client's affected side B. Take over the ambulation and the counsel the UAP later C. Provide client an assistive device, such as a cane or walker D. Tell then UAP to take the client back to his room.

A

The PN notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8 F, pulse 94, respirations 22, and B/P 108/54. Which intervention is most important for the PN to implement? A. Report the findings to the charge nurse B. Monitor the client's temperature hourly C. Offer the client fluids frequently D. Provide care to moisten oral mucous

A

The PN is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? Select all that apply A. Observe the progression of the seizure B. Loosen clothing around the neck C. Pad the side rails with pillows D. Insert a tongue blade between the teeth E. Hold the extremities close to the body

A,B,C

A 12-year-old child is receiving a blood transfusion per infusion pump and begins to complain of "itchy" skin 15 minutes after the unit of blood is started. The child appears flushed. What action should the practical nurse take first? A. Apply lotion to the skin B. Stop the transfusion C. Inspect the infusion site D. Obtain the vital signs

B

A client who is receiving chemotherapy has developed stomatitis. Which instruction should the PN provide the UAP who is assisting with the care of this client? A. Keep the room environment free of unpleasant odors B. Gather supplies for protective environmental precautions C. Assist the client with feeding at meal times D. Provide gentle and meticulous mouth care

B

A female Native American client who is receiving chemotherapy places a native artifact, an Indian medicine wheel in her hospital room. The HCP removes the medicine wheel and tells the client, "This type of thing does not belong in the hospital." Which intervention should the PN implement? A. Teach the client the importance of implementing the chemotherapy regimen B. Act as the client's advocate when discussing the issue with the HCP C. Consult with a Native American healer regarding the proper use of a medicine wheel D. Report the client's feelings of culture shock to the HCP

B

The HCP gives a pregnant women a prescription for one prenatal vitamin with iron daily, and tells her that she needs to increase foods in her diet because her hemoglobin is 8.2 grams/dL. When a list of iron rich foods is given to the client, She tells the PN that she is vegetarian and does not eat anything that "bleeds." Which instruction should the PN provide? Select All That Apply A. Take two prenatal vitamins with iron daily B. Increase green leafy vegetables in the diet C. Oatmeal is a good choice for breakfast D. Add lentils and black beans to soup E. Eat red meat just until the anemia is resolved

B,C,D

An older postoperative client has the nursing diagnosis "impaired mobility related to fear of falling." Which desired outcome best directs the PN's actions for the client? A. The client will ambulate with assistance q4 hours B. The physical therapist will instruct the client in the use of a walker C. The client will use self-affirmation statements to decrease fear D. The PN will place a gait belt on the client prior to ambulation

C

At the first dressing change, the PN tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best? A. You will feel better when you see that the incision is not as bad as you may think. B. It's OK if you don't want to look or talk about mastectomy. I will be available when you're ready C. Part of recovery is accepting your new body image, and you will need to look at your incision D. Would you like me to call another nurse to be here while I show you the wound?

C

Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the PN to review? A. Hemoglobin and Hematocrit B. Serum Calcium C. Serum Creatinine D. WBC

C

In obtaining an orthostatic vital sign measurement, what action should the nurse take first? A. Count the client's radial pulse B. Apply a blood pressure cuff C. Instruct the client to lie supine D. Assist the client to stand upright

C

The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP? A. Explain how to use a communication board B. Document progress in use of communication board C. Encourage voiding by assisting client to bedside commode D. Establish bladder training schedule and training methods

C

The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, "Why did this happen to my child? I just can't cope with this." How should the PN respond? A. Ask her to share how the injury occurred to her child. B. Recommend that she remain calm and positive for her child C. Express that the present situation must be overwhelming D. Determine if someone else can help her cope with this tragedy

C

Thirty minutes after receiving IV morphine, a postoperative client continues yes to rate pain as 7 on 10 point scale. Which action should the PN implement first? A. Call HCP to request a different analgesic B. Determine when morphine can be given again C. Implement complimentary pain relief methods D. Observe dressing to determine presence of bleeding

C

What intervention should the PN implement when raking the rectal temperature of an adult client? A. Lubricate the tip of the thermometer with water B. Gently insert the thermometer 3 inches into the rectum C. Hold the thermometer the entire time while taking the temperature D. Place the client in the right Fowler's position

C

When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the PN to perform instead of assigning to UAP? A. Close the doors to all of the resident's room B. Offer comfort and reassurance to each resident C. Identify the method for transporting and evacuating each resident D. Provide blankets to each of the residents for use during evacuation

C

When caring for a child with sickle cell disease, the PN expects that the child will most likely describe which symptom when experiencing a sickle cell crisis? A. Decreased hemoglobin B. Joint pain C. Fatigue D. Infection

C

The PN assigns an UAP to bathe a client who is on contact precautions due to Clostridum Difficule maintain contact precautions, the PN should instruct the UAP to perform the following actions in which sequence? A.Remove gloves and gown in room B. Put on disposable gown C. Perform standard hand washing D. Repeat standard hand washing E. Don a pair of procedure gloves

C,B,E,A,D

A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond? A. Encourage the client to get plenty of exercise as well as the dietary change B. Provide written information about the seven warning signs of cancer C. Remind the client to make sure that the dairy products are fortified with Vitamin D D. Suggest that an increase in fruits and vegetables is more beneficial

D

A female client tells the PN that her hemorrhoids are inflamed and hurt constantly. Which intervention is best for the PN to implement to complete a focused assessment? A. Determine if the client uses any over-the-counter preparations for hemmorhoids B. Place the client in a standing position, leaning over the exam bed for inspection. C. Position client in left lateral position to inspect perineal area for fissures or sacs D. Ask the client how long she has experienced discomfort related to hemorrhoids.

D

The PN is caring for an older client who was informed about the diagnosis of terminal cancer two days ago. Which intervention wouldbe most helpful for the client's spouse at this time? A. Consultation with the case manager and hospital chaplain B. Visiting after procedures are done to avoid seeing the client in pain C. Participating in the client's care within his/her capabilities and desires D. Information about palliative and hospice care services

D

The PN observes an UAP bathing a bedfast client with the bed in the high position. Which action should the PN take? A. Remain in the room to supervise the UAP B. Determine if the UAP would like assistance C. Assume care of the client immediately D. Instruct the UAP to lower the bed for safety

D

When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma? A. Antiseptic cream B. Petroleum jelly C. Cornstarch D. Stomadhesive

D

When preparing for a bone marrow aspiration, the PN should place the client in which position to ensure access of the aspiration site? A. Supine with a pillow under the lumbar area B. Sitting up and leaning across the over-bed table C. Side-lying with the posterior chest exposed D. Prone with the posterior iliac crest draped

D

Which client information is most important for the PN to consider when providing instructions to the UAP to consider when providing instructions to the UAP about providing morning care to a postoperative client? A. Oriented to person only B. Oxygen saturation measurement of 95 to 96% C. Urinary output of 50 mL/hr D. Blood pressure of 144/84

D

The PN assigns an UAP to assist with the personal care of a client experiencing an acute excaberation of multiple sclerosis. Which instruction should the PN provide the UAP? A. Assist the client with a hot bath B. Encourage self-care but allow rest periods C. Face the client directly when speaking D. Keep head of the bed elevated at all times

B

The PN has added feeding solution to a client's tube feeding system as seen in the picture. Which action should the PN take next? A. Remove the air from the solution bag B. Obtain a piston syringe and irrigation set C. Record the solution added as fluid intake D. Calculate the rate of flow of the solution

B

The PN identifies an electrolyte imbalance, exhibited changes in mental status, and an elevated blood pressure for a client with progressive heart disease. Which intervention should the PN implement first? A. Record usual eating patterns B. Evaluate for muscle cramping C. Document abdominal girth D. Elevate both legs on pillows

B

The PN is assisting the recreational director of a long-term care facility plan outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents? A. An open air concert B. A tea party in the courtyard C. A team ring-toss competition D. A picnic in the park

B

The HCP prescribes heparin 4,500 units subcutaneously once daily. The medication is available in a vial that contains heparin 10,000 units/mL. How many mL should the PN administer?

0.45

The PN is assisting the nurse with admission physical assessment of a client diagnosed with pneumonia. What symptoms are the client likely to exhibit? Select All That Apply A. Dyspnea B. Bradycardia C. Lung crackles D. Ankle Edema E. Painful Cough

A,C,E

A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coomb's test. Which is the implication of this finding? A. The newborn is infected with an infectious blood-borne disease B. The newborn needs phototherapy for physiologic jaundice C. The mother's Rh antibodies are present in the neonatal serum D. The mother no longer needs Rho immune globulin injections

C

A homeless male client with a history of alcohol abuse had a CVA 10 years ago that resulted in left hemiparesis. Today he is brought to the clinic reporting pain in his left leg. He is afebrile, has 4+ pitting edema in the lower left leg, and has minimal swelling of the right leg. Which action should the PN implement first? A. Obtain a blood alcohol test B. Inspect legs for infection or trauma C. Complete a mental status exam D. Inquire about dietary salt intake

B

A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP? A. Pyrixodine with a B complex multivitamin B. Gentamicin 160 mg IM daily C. Rifampin 600 mg PO daily D. Isoniazid 300 mg PO daily

B

At 1200, the practical nurse learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take? A. Administer half of the missed dose immediately B. Administer the missed dose as soon as possible C. Give the missed dose with the next scheduled dose D. Withhold the mossed dose unless seizure activity occurs

B

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 PN to ask the child? A. How much did the child exercise today? B. Did the child perform a finger stick? C. When did the child last urinate? D> Has the child eaten recently?

B

During a routine prenatal visit at the antepartal clinic, a multipara at 35-weeks gestation presents with 2+ edema of the ankles and edema. Which additional information should the PN report to the RN? A. Due date B. Blood pressure C. Gravida and parity D> Fundal height

B

During immediate postoperative period following a total hip placement, which intervention is most important for the PN to implement? A. Encourage client to use walker or cane when ambulating B. Keep client's hip aligned with knees abducted C. Teach client to sit on the side of the bed before standing D. Monitor urinary flow via indwelling catheter

B

Prior to giving digoxin, the PN assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take? A. Withhold the medication and notify the charge nurse B. Give the medication and document the heart rate C. Withhold the medication until the next scheduled dose D. Request the charge nurse to administer the medication

B

The PN administered darbepoetin alfa to a client with Chronic Kidney Disease(CKD). Which serum laboratory value should the PN monitor to gather the effectiveness of this drug? A. Calcium B. Phosphorous C. Hemoglobin D. White Blood Cell Count

B

The PN is reviewing care instructions with a client who has diabetic retinopathy and is experiencing glare around lights. What should the PN reinforce with the client? A. Cover eyes with moist, cool compresses to reduce fasciculations B. Make adjustments to personal schedule to avoid driving at night C. Exert pressure on the inner cants whiners tearing occurs D. Apply an eye shield at bedtime after installing eye drops

B

A client takes one 500 mg calcium tablet twice daily. How many grams of calcium is the client taking daily?

1

A client is scheduled to receive hydroxyzine 75 mg IM postoperatively. The vial contains 50mg/mL. How many mL should the PN administer?

1.5

The UAP reports to the PN that an assigned client experiences SOB when the bed is lowered for bathing. Which action should the PN implement? A. Obtain further data about the client's activity intolerance to position changes B. Advise the UAP to allow the client to rest before completing the bath C. Direct the UAP to obtain vital signs and a pulse oximetry reading. D. Notify the healthcare provider about the client's episode of SOB

B

An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan? A. Plan to have the same nursing staff provide care for the client whenever possible B. Describe the activities available to residents and encourage him to choose the ones he prefers C. Encourage the client to remain on the unit for three weeks until he is oriented to his new surroundings D. Introduce the client to the nursing staff and other residents as soon as possible

A

The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately? A. Swollen and discolored menial shaft B. Prepuce extends over head of penis C. Leaking urine around the top of catheter D. Moist and excavated perineal skin folds

A

A client reports being able to swallow only small bites of solid food and liquids for the last 3 months. The PN should assess the client for what additional information? A. Past traumatic injury to neck B. Daily consumption of hot beverages C. History of alcohol or tobacco use D. Daily dietary intake of roughage

C

The mother of a 9-month-child who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child for the following day. Which response should the PN provide the mother? A. Do not expose other children as the virus is very contagious even without direct contact B. The child will no longer be contagious, no need to take any further precautions C. The child can be around other children but should wear a mask D. Make sure there are no children under the age of 5 months around the infected child.

A

The practical nurse and unlicensed assistive personnel are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? A. Demonstrate to the UAP how to approach the client from the client's left side B. Ask the UAP to leave the room and assess the client's body for bruising C. Carefully observe the interaction between the client and family members. D. Instruct the UAP to protect the client's left side when transferring to chair

A

When reinforcing diet teaching for a client who was diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply A. Orange juice, oranges, bananas B. Preserved meat, apple juice, seeds C. Collard greens, kale, turnips D. Soy Beans, lima beans, spinach E. White grape juice, clear fat-free broth, consommé

A,C,D

At a community immunization clinic, the PN is planning to administer a 1 mL intramuscular injection to a 6-month old. Which action should the PN include in administering the IM injection? Select All That Apply A. Encourage the parent to hold the child securely B. Use a Z-track technique for best absorption C. Inject the needle at a 90 degree angle D. Palpate the landmarks for the deltoid muscle E. Locate the vastus lateralis muscle

A,C,E

The PN is assigning care for a group of clients on the urology medical unit. Which client care interventions should the pN assign to the UAP? Select All That Apply A. Empty bedside drainage unit for a client with indwelling urinary catheter B. Teach the client with fluid restrictions how to measure urine output C. Irrigate an indwelling urinary catheter for a client with bladder suspension D. Transport a urine culture sample to the laboratory E. Obtain a post-voided residual volume

A,E

While performing an inspection of a client's fingernails, the PN observes a suspected abnormality of the nail's shape and character. Which finding should the PN document? A. Clubbed nails B. Splinter hemorrhages C. Longitudinal ridges D. Koilonychia or spoon nails

ABeo

A client has a prescription for a transcutaneous electrical nerve stimulator(TENS) unit for pain management during the postoperative period following a lumbar laminectomy. Which information should the PN reinforce about the action of the adjuvant pain modality? A. The discharge of electricity will distract the client's focus on the pain B. An infusion of medication in the spinal canal will block pain perception C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain

B

The practical nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the PN to take? A. Ask another nurse to go back with the medication when the client's hung up the phone B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication C. Return the medication to the client's drawer on the cart and document the client refused the dose D. Leave the medication with the client, and let him take it when he finishes the conversation.

B

The practical nurse is caring for a client who had a total laryngectomy, left radical neck dissection, and tracheostomy. The client is receiving nasogastric tube feedings via an enteral pump. Today the rate of feeding is increased from 50 ml/hr to 75 ml/her. What parameter should the PN use to evaluate the client's tolerance to the rate of the feeding? A. Daily weight B. Gastric residual volumes C. Bowel Sounds D. Urinary and stool output

B

When administering an analgesic to a client with low back pain, which intervention should the practical nurse implement to promote the effectiveness of the medication? A. Massage the lower back and position the client in proper alignment B. Encourage the client to ambulate frequently and take deep breaths C. Assist client in performing passive and active range of motion exercises D. Give medication with a full glass of water and offer high roughage foods

B

Which action should the PN implement when using standard precautions to provide client care? A. Apply sterile gloves to obtain a finger stick blood sample B. Wear clean exam gloves to perform perineal catheter care C. Replace the needle cap after giving an intramuscular injection D. Wear a paper gown to prevent transmission of droplet pathogens.

B

Which information should the PN collect during admission assessment of a terminally ill client to am acute care facility? A. Name of funeral home to contact B. Client's wishes regarding organ donation C. Contact information for client's next of kin D. Health care proxy information

B

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his progress? A. I don't have any use for those who say disease is going to win B. I've found support I need from my faith and family. C. I think I've had this disease for a long time, but the doctor did not find it D. I understand that this is a disease that occurs mostly in older men

B

While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered and he shows no emotion or expression when speaking. Based on these observation, what documentation should the PN include? A. Impaired verbalization B. Depressed mood C. Flat effect D. Diminished LOC

B

While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement? A. Swab the oral cavity with a washcloth B. Use oral swabs with normal saline C. Provide a Yankauer tip for oral suction D. Support the head with a small pillow

B

While taking the vital signs of an older male client who takes psychotropic medications, the PN notes that he has uncontrollable hand movements and is excessively blinking his eyes. Which information in the client's medical record should the PN review? A. Prescription for lorazepam B. History of Parkinson's disease C. Screening for tardive dyskinesia D. Recent urine drug screen report

B

The ON observes a client's initial postoperative dressing and drains as seen in the picture, Which follow-up actions should the pN implement? Select All That Apply A. Clamp the drainage tubing for the next four hours B. Document the appearance of the wound as inflamed C. Remove the drainage device and apply a pressure dressing D. Report the appearance of the dressing to the charge nurse E. Compress the drainage device before closing the tab

B,D

A PN is competing a focused assessment of an older adult's skin. The PN notes a crusted 0.7 cm lesion on the client's forehead. Which action should the PN take in response to this finding? A. Report the finding to the healthcare provider B. Place a clear occlusive dressing over the site C. Apply a warm compress to remove the crusted area D. Explain that this is a normal skin change with aging

C

A client is admitted to the postoperative surgical unit with two test tubes after a left lobectomy. The ON observed that the chambers are set at the prescribed suction of 20 cm water pressure and tidying occurs with respirations and bubbling. What action should the PN implement? A. Clamp the chest tube to see if the activity stops B. Notify the registered nurse of the malfunction C. Maintain system integrity to promote lung reexpansion D. Apply a partially occlusive dressing toterm-10 chest

C

A client is complaining of a tingling sensation in the fingers, nose tip, and ear lobes 24-hours after a total thyroidectomy. Which measure should the PN implement first? A. Apply sequential compression devices bilaterally B. Initiate prescribed L-thyroxine replacement therapy C. Obtain prescribed calcium gluconate for tetany D. Prepare for emergency tracheotomy at the bedside

C

A female client taking a liquid iron preparation expresses concern that her tooth color has darkened since starting the medication. What action should the PN implement? A. Teach the client to use a straw when taking the medication to reduce further tooth staining B. Advise the client to withhold further doses until consulting with the HCP C. Reassure the client that this change indicates the medication is having the desired effect D. Determine if the client is also experiencing mouth or gum pain and difficulty swallowing

C

A female client who has been taking oral contraceptives for the past year comes in the clinic for an annual exam. Which finding is most important for the PN to report to the HCP? A. Breast tenderness B. Change in menstrual flow C. Left calf pain D> Weight gain of 5 pounds

C

A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. Which immediate intervention should the PN implement? A. Stimulate the infant to cry B. Give oxygen by positive pressure C. Suction the oral and nasal passages D. Turn the infant onto the right side

C

An 8-year old is placed in 90-90 traction for a fractured femur that resulted from a motor vehicle collision. Which finding requires further action by the PN? A. No BM for two days B. Mother helps child change positions C. Weights are touching the foot of the bed D. Child moves the toes freely when tickled

C

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement? A. Ask family members to remain with the client in the evenings from 5 to 8 pm B. Administer a prescribed PRN benzodiazepine at the onset of a confused state C. Ensure that the client is assigned to a room close to the nurses' station D. Postpone administration of nighttime medications until after 11 pm.

C

The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was 0 station. An hour later, the client tells the PN that she wants to go the bathroom. Which action is most important for the PN to implement? A. Review the fetal heart rate and contraction pattern B. Check the perineum for increase in bloody show C. Request nurse to check client's cervical dilation D. Palpate the client's bladder for distention

C

The PN observes an UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take? A. Stop the procedure and tell the UAP to place the client in a fowler's position B. Praise the UAP for doing the ora; hygiene but encourage family participation C. Tell the UAP to continue because the unconscious client is positioned safely D. Enroll the UAP in a hospital education class on conducting safe client care

C

While ambulating in the hallway following an appendectomy yesterday, a client complains of chest tightness and shortness fo breath. Which action should the PN implement first? A. Administer sublingual nitroglycerin B. Assist the client back to the room C. Have the client sit down in the hall D. Obtain a 12 lead electrocardiogram

C

While caring for a client with an AV fistula in the left forearm, the PN observed a palpable bussing sensation over the fistula. What action should the PN take? A. Loosen the fistula dressing B. Report the presence of bounding pulse C. Document that the fistula is intact D. Apply gentle pressure over the side

C

While turning and positioning a bedfast client, the PN observes that the client is dyspneic. Which action should the PN take first? A. Apply a pulse oximeter B. Measure blood pressure C> Notify the charge nurse D. Observe pressure areas

C

The practical nurse is assisting the nurse with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the PN take? A. Omit compelling this section of the assessment form B. Ask her if she would like an interpreter to ask her the question C. Reword the question in case the client did not understand D. Watch the client's response when asked a different question

D

A male client who has been diagnosed with schizophrenia is withdrawn, isolates himself in the day room, and answers question with one or two word responses. This morning, the practical nurse observes that he is diaphoretic and is pacing in the hall. Which intervention is most important to the PN to implement? A. Persuade the client to lie down B. Provide a drink high in electrolytes C. Observe the client during the shift D. Measure appropriate vital signs

D

An adult client who weighs 150 pounds has partial-thickness and full-thickness burns over 40% of the body from a house fire. After admission, which observation is most important for the practical nurse to report immediately? A. Poor appetite and refusing to eat B. Systolic blood pressure at 102 C. Painful moaning and crying D. Urinary Output of 20ml/hr

D

At the end of a 12-hour shift, the PN observes the urine in a client's drainage bag as seen in the picture. Which action should the PN take next? A. Offer to administer a prescribed PRN analgesic B. Obtain a fingers rick capillary glucose level C. Determine if the client's bladder feels distended D. Note the most recent white blood cell count

D

The PN is assigned to administer medications in a long term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the PN to take prior administering the medications this resident? term-14 A. Ask a regular staff member to confirm the resident's identity B. Hold the medication until a family member again C. Re-orient the resident to name, place, and situation D. Confirm the room and bed numbers with those on the medication record.

D

The PN is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body? A. In front of the body to lean on while stepping forward B. On the opposite side of the affected extremity C. Approximately one foot way from the body to stabilize balance D. On the same side as the affected extremity

D

The PN is caring for an elderly female client who tells the PN, "When I sneeze, I wet my pants." After discussing the client's complaint with the charge nurse, the PN plans to reinforce teaching that the client has received about the importance of Kegel exercises.WHat muscles are involved in these exercises? A. Pectoral muscles B. Buttock muscles C. Abdominal muscles D. Pelvic floor muscles

D

The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the cloth used to anesthetize the eye if eye pain is experienced. What action should the PN implement? A. Document in the chart that the client understands then action and the use of eye drops B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common C. Reteach the client about the action of the eye drops to decrease pressure in the eyes D. Explain to the client that they eye drops do provide pain relief, but do not anesthetize the eyes.

D

The PN observes an UAP prepare to exit a client's room. The UAP's hands appear visibly soiled as the UAP uses a hand rub for 19 seconds to cleanse the hands. Which action should the PN take? A. Confirm that the UAP completed hand hygiene correctly B. Instruct the UAP to wash the hands for one minute C. Ask the UAP why the hands were so obviously soiled D. Advise the UAP to use the hand rub for 30 seconds

D

The PN reviews client's medication history and learns that the client takes an anticoagulant and has recently started taking phenytoin. Which instruction should the PN provide when assigning the client's morning care to an UAP? A. Measure the temperature every 4 hours B. Elevate both feet on two pillows C. Initiate hourly turning schedule D. Protect skin from injury and bruising

D

The UAP reports to the PN that a client refused to bathe for the third consecutive day. Which action is best for the PN to take? A. Explain the importance of good hygiene to the client B. Ask family members to encourage the client to bathe C> Reschedule the bath for the following day D. Ask the client why the bath was refused

D

The practical nurse is caring for a client whose urine drug screen is positive for cocaine, Which behavior is this client likely to exhibit during cocaine withdrawal? A. Elevated energy level B. Euphoria C. High self-esteem D. Powerful craving for more

D