Hesi 2
The nurse is caring for a client with a coronary artery disease who admitted with intermittent chest pain. The admission laboratory results indicate elevations and troponin and creatine phosphokinase myoglobin isoenzyme levels. What should the pen considered the most significant risk for this client on the second day of omission A. The lab results indicate respecters for TIA, vital signs should be monitored. B. THE CLIENT IS AT RISK FOR A PULMONARY EMBOLISM IN LIFESTYLE MODIFICATIONS NEED TO BE implemented C. THE CLIENT IS AT RISK FOR RECURRENT, LONG-TERM ANGINA PAIN, SUBSEQUENT MI D. THE LAB RESULTS INDICATE MYOCARDIAL DAMAGE, AND THE CLIENT IS AT RISK FOR CARDIAC DYSRHYTHMIAS
.D. THE LAB RESULTS INDICATE MYOCARDIAL DAMAGE, AND THE CLIENT IS AT RISK FOR CARDIAC DYSRHYTHMIAS
While caring for a client one day following a thyroidectomy, the PN notes that the client's voice is hoarse. Which action should the PN take? A. Administer humidified oxygen per nasal cannula B. Ensure that the drainage device is compressed C. Notify the unit charge of the finding D. Obtain the cup of ice chips for the client
A. Administer humidified oxygen per nasal cannula
The PN is feeding a 2 month old male infant with HF due to a ventricular septal defect. Which intervention should the PN implement A. Allow infant to rest before feeding B. Weigh before and after feeding C. Feed the infant when he cries D. Insert a nasogastric feeding tube
A. Allow infant to rest before feeding
The practical nurse notices that a clients urine is pale yellow, with a cloudy appearance, and has a foul odor. Which assessment should the PN complete next? A. Ask the client about urinary frequency B. Palpate the bladder area for distension C. Assess skin appearance for elasticity D. Observe the feet and legs for swelling
A. Ask the client about urinary frequency
The PN is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks is the surgical opening will be visible. Which action should the PN implement? A. Ask the client if he finished the bowel sterilization program B. Verify that the client has been NPO for the past 24 hours C. Review the clients expectations of elimination after surgery D. Determine if this is the first indwelling catheter the client has had
A. Ask the client if he finished the bowel sterilization program
Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the PN? A. Checks the medical record for the correct signed consent form prior to the examination B. Explains the examination and asks the client to sign the consent form C. Explains to a family member and obtains their signature for consent form D. Asks if the client understands the exam and why the consent form must be signed.
A. Checks the medical record for the correct signed consent form prior to the examination
The practical nurse PN, who is working at the charge nurse on the Night Shift of a large, long-term care facility notice is that an unlicensed assistive personnel uses for handwashing technique do UAP is assigned to care for a client who has had uncontrollable diarrhea for the last eight hours which intervention should the pn implement? A. Demonstrate good handwashing technique to the UPA and observe for compliance B. Reassigned a UAP to another client who does not currently have an infection. C. Encourage the UPA to use anti-septic Joe, when entering and exiting the clients room. D. Report the evaluation of the APs handwashing technique to the nursing supervisor.
A. Demonstrate good handwashing technique to the UPA and observe for compliance
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. In approaching the client, what intervention should the PN implement first? A. Describe functions of the PN B. Review client rights of hospitalization C. Explain daily schedule of unit activities D. Offer the client a PRN medication
A. Describe functions of the PN
The PN is charting vital signs on a hand written flow sheet and realizes that an error has been made. What should the PN do to rectify this error? A. Draw one line through the entry and insert the correct information B. Chart the correct information in the next column C. Olibiterate the entry and reset correct information D. Notify the charge nurse that the entry needs to be revised
A. Draw one line through the entry and insert the correct information
The spouse of a hospitalized client asks the PN for acetaminophen for a tension headache. Which action should the PN take? A. Explain that medication can only be provided to clients B. Determine if the spouse has any medication allergies C. Request the pharmacy to send acetaminophen to the unit D. Give the spouse acetaminophen from the nurse's personal supply
A. Explain that medication can only be provided to clients
A client who is at full term gestation is in active labor and complains of a cramp in her leg. Which intervention should the PN implement? A. Extend the leg and flex the foot B. Check the pedal pulse in the affected leg C. Massage the calf and foot D. Elevate the leg above the heart
A. Extend the leg and flex the foot
A client tells the PN that he is afraid about his scheduled surgery. How should the PN respond?
A. I was afraid before I had surgery, too B. It is normal to have some fears before surgery C. Would you like to speak with my surgeon? D. Tell me what is making you feel afraid.
The parents of a child with pre diabetes report to the PN that the child wants to join a soccer team. Which action is best for the PN to implement? A. Instruct the family about the need to adjust the insulin dose before excerise B. Recommend an increase in caloric intake to avoid excessive weight loss C. Suggest a less strenuous activity to reduce the risk for dehydration D. Reassure the parents that increased physical activity reduces the risk for diabetes
A. Instruct the family about the need to adjust the insulin dose before excerise
A chronically depressed older male client of a long term care facility becomes more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the PN is likely to be most helpful to this client? A. May I sit with you for a while? B. I know you are sad about not seeing your family as often C. Come into the recreation area. We have your favorite card game D. Why do you want to stay in your room today?
A. May I sit with you for a while?
The PN is caring for a client who was admitted after experiencing a generalized tonic clinic seizure. When witnessing the child began to seize again, which actions should the PN implement immediately? A. Hold the extremities close to the body B. Observe the progression of the seizure C. Insert a tongue blade between the teeth D. Loosen clothing around the neck E. Pad the side rail with pillows
B, D, E
The practical nurse is reinforcing discharge instructions with a client who is two days post partum. Which instruction should the PN reinforce with the client about the lochia turning red again? A. increase your exercise regimen to firm up abdominal muscles B. Don't worry, this is a normal occurrence C. Notify your healthcare provider and reduce your activity level D. Sit in a tub of warm water for 15 minutes
B. Don't worry, this is a normal occurrence
The practical nurse is providing care for a client who is receiving an intravenous antibiotic to treat an infection. Which assessment findings,require the most immediate action by the PN? A. Low grade fever with diaphoresis B. Hives with pruritis C. Warm skin with elastic turgor D. Dry mouth with thirst
B. Hives with pruritis
A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drug of choice are cocaine and heroin. What is the greatest health risk for this client? A. Hepatitis B. Hypertention C. Diabetes D. Glaucoma
B. Hypertention
A new unlicensed assistive personnel is completing an orientation assignment and is caring for an immobilized client who needs a complete bed bath. Which is the best way for the PN to evaluate the UAP performance A. Request the UAP to report and chart when the bath is complete B. Inspect the clients skin near the end of the bathing procedure C. Ask another UAP to help the orientee to ensure satisfactory care D. Verify with the client that the bath was complete and thorough
B. Inspect the clients skin near the end of the bathing procedure
The practical nurse works in a facility that has just been placed on lockdown for a radiation dispersion event which action should the nurse take to protect the client? A. Cover entryways with plastic sheeting. B. Move clients into the interior room. C. Open the windows and vents D. Turn exhaust fans to high
B. Move clients into the interior room
A 15 year old male who is mildly mentally disable is admitted to the adolescent unit because he repeatedly refuses to complete personal hygiene. The healthcare provider prescribes that the client brush his teeth 3x per day. In the psych team conference, a behavior modification program is not recommended to engage the clients participation. When implementing this technique, which reinforcement is best for the pn to provide? A. Candy for each successful hygiene task, like brushing his teeth B. Preferred activities or tokens for each compliance C. Pro ledge restriction or fines for refusals to complete a hygienic task D. Unit tasks for each omission of teeth brushing
B. Preferred activities or tokens for each compliance
A community hit by a hurricane has suffered mass destruction and flooding. Sewage facilities are non functioning and the area is contaminated with human excreta. The nurse is developing a plan of care for clients diagnosed with cholera after an outbreak. Which intervention has the highest priority? A. Administer prophylactic antibiotics as prescribed B. Provide fluid and electrolyte replacement C. Isolate all infectious diarrhea victims D. Administer cholera vaccine
B. Provide fluid and electrolyte replacement
A client who had orthopedic surgery 3 days ago complains of difficulty sleeping. Which initial intervention is best for the PN to implement? A. Provide a cup of hot chocolate at bedtime B. Reposition the client and provide a back rub C. Administer a PRN prescription for pain D. Offer the client a prescribed sleep medication
B. Reposition the client and provide a back rub
A male client with polycythemia Vera is scheduled for phlebotomy in the units procedure room. What action should the practical nurse implement when coordinating departmental services for this procedure? A. Notify the blood bank about the scheduled phlebotomy procedure B. Schedule the treatment with special procedures department C. Ensure that chest x ray and other radiological reports are available D. Ask pharmacy to deliver an additional PRN dose of analgesic.
B. Schedule the treatment with special procedures department
An older client tells the home health care Pn about experiencing dizziness from getting out of bed, which assessment is most important for the pn to obtain? A. Pulse deficit. B. Standing blood pressure. C. Apical heart rate. D. Oxygen saturation.
B. Standing blood pressure
The PN observes two UAP turning an older client who had a his arthoplasty with prosthesis placement 4 hours ago. Which observation by the PN indicates that the UAP needs additional information? A. A turning sheet is used under the client for turning and repositioning B. The client is told to keep both legs straight together while turning C. An abduction pillow is placed between the clients legs when positioning D. The UAP's keep their backs straight and knees bent when moving the client
B. The client is told to keep both legs straight together while turning
The PN receives shift report for four newborns in the full term newborn nursery. Which infant should the PN assess first? A. 1 day old with a positive babinski reflex B. 6 hour old with a large sacral stork bite C. 10 hour old with a circumoral cyanosis D. 2 day old with negative ortolanis sign
C. 10 hour old with a circumoral cyanosis
After change of shift report, the PN makes rounds on the post operative unit. Which client finding necessitates the immediate action of the PN? A. An older client whose blood pressure is 100/70 after receiving meperidine for pain related to a hip fracture B. A client who has pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy C. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal D. A client who has brown green bile draining from a T tube after a cholecystectomy for Chloelithiasis
C. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement? A. Encourage the child to drink adequate amounts of cool clear liquids B. Monitor the child's oxygen saturation via a pulse oximeter C. Administer a dose of acetaminophen per PRN prescription D. Instruct the mother to play with the child for stimulation and distraction
C. Administer a dose of acetaminophen per PRN prescription
The PN observes a UAP prepare to exit a clients room. The UAPs hands appear visibly soiled as the UAP uses a hand rub for 10 seconds to cleanse the hands. Which action should the PN take A. Ask the UAP why the hands were so obviously soiled B. Instruct the UAP to wash the hands for one minute C. Advise the UAP to use the hand rub for 30 seconds D. Confirm that the UAP completed hand hygiene correctly
C. Advise the UAP to use the hand rub for 30 seconds
The PN observes a client with the diagnosis of schizophrenia sitting all alone and talking quietly. Which action should the PN take? A. Have UAP escort the client down to his room B. Record the event but do not disturb the client C. Ask the client if he is currently hearing voices D. Administer a PRN dose of halopendol
C. Ask the client if he is currently hearing voices
During a routine prenatal visit at the antepartal clinic, a multiparty at 35 weeks gestation presents with 2+ edema of the ankles and feet. Which additional information should the PN report to the RN? A. Fundal height B. Due date C. Blood pressure D. Gravida and parity
C. Blood pressure
A clients most recent vital signs are BP 122/70 mm Hg, HR 78 bpm, RR 20 bpm, and O2 97%. When the client reports dizziness after quickly rising, which finding should the PN expect on reassessment? A. Oxygen saturation 96% B. RR 12 breaths/minute C. Blood pressure 100/64 mm Hg D. Heart rate 88 beats/minute
C. Blood pressure 100/64 mm Hg
A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrghaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what action? A. Using a tight seal around the mouth piece B. Exhaling slowly after two seconds C. Blowing forcefully into the mouthpiece D. Sitting upright during treatment
C. Blowing forcefully into the mouthpiece
Before removing the nasogastric tube from a postoperative client, which assessment is most important for the PN to complete? A. Body temperature B. Incisional pain C. Bowel sounds D. Blood pressure
C. Bowel sounds
The practical nurse is preparing for shift change which task has the highest priority, and should be completed first? A. Clean up and organize the nurses workstation. B. Verify completion of all new prescriptions. C. Calculate and record intake and output D. Write a narrative shift summary for each client.
C. Calculate and record intake and output
The PN is caring for a client with hiv who is receiving NRTI. the client reports experiencing malaise, fatigue, and anorexia. The PN observes the clients respirations are 30 breaths/min. Which lab result is most important for the PN to review? A. Liver function tests B. Basic metabolic panel C. Complete blood count D. Arterial blood gas
C. Complete blood count
The PN is performing stoma care with a client. While cleaning around the stoma, the PN noticed blood on the washcloth. Which action should the PN take next? ** watch video* A. Stop the stomach care and notify the healthcare provider B. Place a pre moistened dressing on the stomal site C. Continue to clean around the skin surrounding the stomal site D. Apply firm pressure with a dry gauze to the stoma
C. Continue to clean around the skin surrounding the stomal site
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. Determine the method for transporting and evacuating each resident D. Provide blankets to each of the residents for use during evacuation
C. Determine the method for transporting and evacuating each resident
The PN learns in report that a client has jugular vein dissension. Which technique should the PN use to confirm this finding? A. Palpation B. Auscultation C. Inspection D. Percussion
C. Inspection
A client is receiving an epidural anesthesia during labor. Which observation is the most important adverse effect that the PN should assess for following the administration of the epidural A. Urinary retention B. A continuous headache C. Maternal hypotension D. A vaginal hematoma
C. Maternal hypotension
The practical nurse is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication? A. Eccymosis and pertechiae on the legs B. Ulceration on the corner of the upper lip C. Red papules and pustules on the face D. Red welts widespread over the chest
C. Red papules and pustules on the face
The home health nurse observes a client attempting to open a childproof medication container. After being unsuccessful in opening the container, the client throws it across the room and cursed loudly. Which action should the PN implement A. Allow the client to display acts of frustration B. Transfer the medication to a bottle that easily opens C. Retrieve the medication bottle and remove the cap D. Discuss medication containers that are available
C. Retrieve the medication bottle and remove the cap
The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? A. The child looks at the floore when answering the nurse's questions B. The mother's version of the injury is different from the child's version C. The child has several abrasions on the chest and legs D. The mother refuses to answer questions about family history
C. The child has several abrasions on the chest and legs
In describing the Atmos individual for developing breast cancer, the PN should recognize which female client is having the highest risk? A. 35 year old with trauma to the breast B. 50-year-old Caucasian has never had a mammogram. C. 40 year old African-American with hypertension. D. 32 year-old whose mother had breast cancer
D. 32 year-old whose mother had breast cancer
The PN is performing integumentary focused assessments for a group of clients. Which client should the PN recognize as being at greatest risk for delayed wound healing from a pressure related ulcer? A. A client with multiple sclerosis who is malnourished B. a client with heart failure who experiences urinary incontinence C. A client with dementia who has fecal incontinence D. A client who has hypertension and cellulitis of the left leg
D. A client who has hypertension and cellulitis of the left leg
The PN is assigning tasks to a UAP who is giving basic care to a group of residents in a long term care facility. Which clients tasks should be completed by a pn rather than a UAP? A. A client with urinary urgency and incontinence who is asking for a bedpan B. A client with a full urinary bedside drainage unit after receiving a diuretic C. A client with parapalegia who needs an urinary condom cath change D. A client with a continuous urinary bladder irrigation via a 3 way catheter
D. A client with a continuous urinary bladder irrigation via a 3 way catheter
The PN is making a home visit to an older male adult who was recently diagnosed with herpes zoster (shingles) the client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take? A. Notify the nursing supervisor of the uncontrolled pain B. Obtain the oxygen tank for home administration C. Give the next prescribed dose of antiviral medication D. Administer a PRN dose of analgesic
D. Administer a PRN dose of analgesic
The practical nurse is assisting the recreational director of a long term care facility in planning outdoor activities for the wheelchair bound older residents who are mentally alert. Which activity should the PN suggest that meets the physical and social needs of those residents? A. An outdoor concert B. A picnic in the park C. A tea party in the court yard D. An outdoor game of balloon volleyball
D. An outdoor game of balloon volleyball
The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds. The infant is jittery and has a heel stick glucose level of 40 mg/dl 30 minutes after birth. Based on this information, which intervention should the practical nurse implement first? A. Repeat the heel stick for glucose in one hour B. Assess for signs of hypocalcemia C. Offer nipple feedings of 10% dextrose D. Begin frequent feedings of breast milk or formula
D. Begin frequent feedings of breast milk or formula
The UAP reports to the practical nurse that a male client with fluid volume overload will not allow the uap to obtain his daily weight. Which action should the PN implement? A. Include noncompliance as a priority problem B. Calculate the clients weight based on the first 24 hour fluid intake and output C. Advise the UAP to re attempt the daily weight after the client eats breakfast D. Consult with the client about his reasons for refusal to be weighed
D. Consult with the client about his reasons for refusal to be weighed
The mother of a young child with eczema asks about the type of clothing that is best for her child's comfort. Which choice should the practical nurse recommend? A. Rayon B. Silk C. Polyester D. Cotton
D. Cotton
The practical nurse and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement? A. Ask the UAP to leave the room and assess the clients body for bruising B. Carefully observe the interaction between the client and family members C. Instruct the UAP to protect the clients left side when transferring to a chair D. Demonstrate the UAP how to approach the client from the clients side
D. Demonstrate the UAP how to approach the client from the clients side
What is the first intervention for the 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 clients refusal on the medication record D. Determine the clients reasoning for refusing the meds
D. Determine the clients reasoning for refusing the meds
To minimize separation anxiety in a hospitalized, two-year-old child which nursing intervention is the best for the practical nurse to implement? A. Provide privacy B. Explain procedures and routines. C. Encourage parents to room in. D. Encourage contact with children of the same age.
D. Encourage contact with children of the same age.
A client who is receiving a statin medication reports the onset of muscle soreness and fatigue, and the PN notes that the clients skin is warm to touch. Which action by the PN takes priority? A. Administer a PRN dose of acetaminophen B. Report the findings to the charge nurse C. Monitor the clients serum lipid levels D. Encourage the client to drink fluids
D. Encourage the client to drink fluids
An older client with pernicious anemia uses hot packs to loosen psoriatic plaques. The PN who assists with home care twice weekly should refer to which finding to the home health care charge nurse? A. Areas of decreased pigmentation B. Yellow white scales on the skin C. Brown spots on hands and arms D. Erythema and edematous areas
D. Erythema and edematous areas
The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops should be used to anesthetize the eye if eye pain is experienced. What action should the PN implement? A. Reteach the client about the action of other eye drops to decrease pressure in the eyes B. Document in the chart that the client understands the action and the use of eye drops. C. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common D. Explain to the client that the eye drops do provide pain relief, but do not anesthetize the eyes
D. Explain to the client that the eye drops do provide pain relief, but do not anesthetize the eyes
The PN is as auscultating a clients lung sounds. Which description should the PN use to document this sound? *listen to audio A. Rhonchi B. Wheeze C. Stridor D. Fine crackles
D. Fine crackles
Which action by the pn indicates the best understanding of the principles related to medical asepsis and effective hand washing? A. Turn the water volume to a low level to decrease splashing B. Dry the hands above the wrists first to dry them clean to dirty C. Use antibacterial hand gel instead of handwashing between clients D. Hold the hands lower than the elbows ro promote microbe removal
D. Hold the hands lower than the elbows ro promote microbe removal
The PN observes an unlicensed assistive personnel bathing a bed fast client with the bed in the high position. Which action should the PN take? A. Determine if the UAP would like assistance B. Remain in the room to supervise the UAP C. Assume care of the client immediately D. Instruct the UAP to lower the bed for safety
D. Instruct the UAP to lower the bed for safety
When administering an analgesic to a client with low back pain, which intervention should the PN implement to promote the effectiveness of the medication? A. Give medication with a full glass of water and offer high roughage foods B. Assist client in performing passive and active ROM C. Encourage the client to ambulate frequently and take deep breaths D. Massage the lower back and position the client in proper alignment
D. Massage the lower back and position the client in proper alignment
A client reports pain, numbness, and tingling sensation in the lower legs. How should the PN document this finding? A. Acute pain B. Visceral pain C. Novice price pain D. Neuropathic pain
D. Neuropathic pain
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the PN who is preparing to insert the catheter in a female client who weighs 50 kg. Which action should the PN take first? A. Ask the client if she has previously been catheterized B. Position the client and observe the urinary meats C. Consult with the charge nurse about the catheter D. Obtain a 30 ml syringe and a vile of sterile water
D. Obtain a 30 ml syringe and a vile of sterile water
A male client tells the practical nurse 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. Encourage the client to continue with this plan to reduce his risk for cancer B. Explain to the client that obesity is a more significant health risk than smoking C. Remind the client that he is likely to gain weight when attempting to stop smoking 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 with irritable bowel syndrome is receiving dicyclomine, an anticholengeric drug. Prior to administering the next dose, the PN determines that the clients mucous membranes are dry, and the client reports having a dry mouth. Which action should the PN take? A. Check vital signs B. Notify charge nurse C. Monitor hemoglobin D. Provide oral care
D. Provide oral care
The parents of a 4 week old male infant report that he eats well but vomits after each feeding. Which finding should the PN identify if the baby is receiving inadequate nutrition? A. Absent Moro reflex B. Hypoactive bowel sounds C. Tachypnea D. Sunken fontanels
D. Sunken fontanels
A client whose first child was delivered by cesarean section is 20 weeks pregnant with her second child and wishes to have a vaginal birth after cesarean. Which information is most important for the practical nurse to obtain? A. Clients intent regarding breast feeding or newborn B. History of contracting herpes simplex virus C. Religious preference of the clients family D. The type of uterine incision used for previous birth
D. The type of uterine incision used for previous birth
A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the practical nurse observe when administering direct care to the client? A. Rotate the assignment with other staff during the shift B. Minimal time, maximum distance, and protective shielding C. Standard precautions with negative pressure isolation D. Virtual observation and wear a film badge for exposure
D. Virtual observation and wear a film badge for exposure
A client with OCD reports "thoughts stick in my mind and the rituals I use are stupid, but I cannot control them." People laugh at me but they don't understand how awful it is. I am a burden to my family because I can not hold a job. I do not know how much longer I can live this way." Which information is most important for the PN to ask in response to the clients statements?
Determine what makes the client think people are laughing
