HESI 1 Remediation Questions

A client is admitted with bacterial meningitis. Which intervention is most important for the practical nurse (PN)? Assess pain rating. Obtain vital signs. Dim the lights in the room. Implement droplet precautions.

Implement droplet precautions. Rationale Bacterial meningitis is spread through droplet transmission, which should be implemented first to protect staff and visitors and also to prevent nosocomial infections.

What is the most important action for the practical nurse (PN) who is implementing a standing order? 1. Compare the order with the client's current status. 2. Confirm the order with the healthcare provider. 3. Transcribe the order into the record. 4. Verify the order with another nurse.

1. Compare the order with the client's current status. Rationale The implementation of standing orders requires the PN to use clinical judgment. Comparing the client's current status with the order is one way to apply clinical judgment.

When determining if the client is compliant with a prescribed medication regimen, which question is best for the practical nurse (PN) to ask? 1. "When and where do you take this pill at home?" 2. "Do you have any of the medication's side effects?" 3. "Why was this medication prescribed for you?" 4. "Are you taking this medication twice a day?"

1. "When and where do you take this pill at home?" Rationale Having the patient describe the medication administration routine used at home helps the PN to evaluate the client's knowledge of the medication regime and detect any indications of misinformation or non-adherence.

Which client needs immediate action by the practical nurse (PN)? 1. An older client who is climbing over the side rails. 2. A female client with depression who is crying. 3. A male client with unstable angina who wants to go home. 4. An older client who vomited once during the last shift.

1. An older client who is climbing over the side rails. Rationale The client who is climbing out of bed, over the side rails is a safety priority and needs immediate intervention.

Which intervention is most important for the practical nurse (PN) to implement to decrease the number of falls for clients in a long-term care facility? Ask about the need to use bathroom. Determine the client's mental status. Inquire about the client's level of pain. Ensure that the floor is free of clutter.

Ask about the need to use bathroom. Rationale One of the most common reasons for falls of clients in a long-term care facility is getting up to go to the bathroom without assistance, so the PN should regularly ask a client about the need to use the bathroom.

While taking an adult's vital signs, the practical nurse (PN) notes an irregular radial pulse. What action should the PN implement to obtain the most accurate assessment? Use a Doppler for the radial pulse while monitoring the apical. Obtain the radial pulse again for one minute followed by the apical. Perform an apical-radial pulse assessment with another nurse. Verify the finding by counting the apical pulse using a stethoscope.

Perform an apical-radial pulse assessment with another nurse. Rationale An apical-radial pulse provides the most objective comparison when one nurse obtains the radial pulse and another nurse simultaneously auscultates the apical pulse. When one nurse collects both rates, either at the same or separate times, the data obtained is less accurate.

The practical nurse (PN) observes a client who begins to choke during a meal. After determining that the client cannot speak, what action should the PN implement? Initiate cardiopulmonary resuscitation (CPR). Administer four upward abdominal thrusts. Sweep the airway with a hooked index finger. Place a fist halfway between the xiphoid process and umbilicus.

Place a fist halfway between the xiphoid process and umbilicus. Rationale After confirming a victim with foreign body airway obstruction (FBAO) cannot speak, the first should be placed between the xiphoid process and umbilicus (D), and a rapid sequence of abdominal thrusts should be administered until the FBAO is relieved. If the victim becomes unresponsive, CPR should be initiated after activating EMS.

The practical nurse (PN) is assessing a client and obtains a pulse rate of 120 beats/minute, respirations of 28 breaths/minute, and a blood pressure of 80/60. Which action should the PN take first? Determine the client's orientation status. Encourage client to take slow deep breaths. Position the client flat in the bed. Measure the client's SpO2 using a pulse oximeter.

Position the client flat in the bed. Rationale The client is hypotensive, so the first action is to place the client's head of the bed flat to increase cerebral circulation. Based on the client's vital signs, the client's orientation status should be evaluated next.

The practical nurse (PN) is assisting a client with an ileostomy appliance to shower. Which personal protective equipment (PPE) must the PN use? 1. Gown. 2. Gloves. 3. Mask. 4. Eye shield. 5. Shoe covers.

1. Gown. 2. Gloves 4. Eye shield. 5. Shoe covers. Rationale Gown, gloves, eye shield, and shoe covers are to be worn to provide protection because of the likelihood of exposure to bodily fluids. A mask is not needed because the client is not on droplet or airborne precautions.

The practical nurse (PN) is providing skin care to an older male client who has the tendency to stay on his left side in a lying position. Which bony prominence should the PN identify as the site most likely to develop alterations in skin integrity? 1. Ilium. 2. Heels. 3. Sacrum. 4. Scapula.

1. Ilium. Rationale A client who tends to return to the same side-lying position places pressure over the bony prominence of the ilium, which is at a increase risk for a break in skin integrity on that bony prominence.

The healthcare provider calls the nurses' station to give telephone call prescriptions for a client who is recently admitted to the unit. The practical nurse (PN) is unsure of the prescription given by the healthcare provider. Which action should the PN take? 1. Read back the prescription to the healthcare provider. 2. Ask another nurse to listen to the healthcare provider's prescription. 3. Explain that the PN is unable to accept the telephone prescription. 4. Clarify the prescription specifics with the pharmacist.

1. Read back the prescription to the healthcare provider. Rationale All verbal or telephone prescriptions should be repeated and read back to the healthcare provider for verification. The verbal instructions from the healthcare provider should be clarified the prescribing healthcare provider, as the prescription is received by the nurse, if the nurse has any questions regarding the verbal order.

Which intervention is most important for the practical nurse (PN) to implement to decrease the number of falls for clients in a long-term care facility? 1. Ask about the need to use bathroom. 2. Determine the client's mental status. 3. Inquire about the client's level of pain. 4. Ensure that the floor is free of clutter.

1. Ask about the need to use bathroom. Rationale One of the most common reasons for falls of clients in a long-term care facility is getting up to go to the bathroom without assistance, so the PN should regularly ask a client about the need to use the bathroom.

The practical nurse (PN) is reviewing the schedule of yearly inservice programs for competency-based nursing care. Which criteria should the PN use in selecting programs that provide the best content to maintain nursing competency? 1. Complex procedures that are done only a few times a month. 2. Techniques that involve management of biohazard waste products. 3. Competency demonstrated in orientation with electronic medication administration. 4. Urgent needs identified by quality assurance to ensure national patient safety goals.

1. Complex procedures that are done only a few times a month. Rationale Competency-based nursing care should be established with yearly inservice education to ensure staff competency. Refresher inservice for procedures that are used infrequently, are potentially invasive, and pose safety risks for the client should be selected for annual validation of competency. To ensure client safety, urgent change in policy or procedure identified by quality assurance studies should have been already addressed immediately, and not as a yearly competency.

A client who is postoperative is receiving an infusion at 80 ml/hour. At the end of 8 postoperative hours, the practical nurse (PN) documents that the client tolerated 100 ml oral intake of ice chips, and urinary output is 1,100 ml. What action should the PN take? 1. Document the intake and output findings. 2. Check the client for dry mucous membranes. 3. Obtain a prescription to increase the IV fluids. 4. Monitor for signs of electrolyte imbalances.

1. Document the intake and output findings. Rationale At the end of the first 8 postoperative hours, the client's intake (total of 740 ml, 640 ml IV & 100 ml oral) and output (1,100 ml) should be documented. Although determining if the client needs additional oral fluids should be implemented, the client's fluid balance is adequate at this time.

The practical nurse (PN) is caring for a male client who wears a hearing aide. Which client behavior should the PN identify that indicates further evaluation of the client's ability to hear? 1. Does not respond when his name is called from behind. 2. Turns off TV to hear when the nurse speaks. 3. States that he frequently sleeps through the alarm clock. 4. Reports intermittent tinnitus that is increasing.

1. Does not respond when his name is called from behind. Rationale Hearing from out-of-sight sources is dependent on air conduction of sound waves, so the client's unresponsiveness to his name should be evaluated further to determine if his hearing or hearing aide function is impaired.

hich finding should the practical nurse (PN) report to the healthcare provider prior to administering as IV infusion with added potassium chloride (KCL)? Oral temperature of 100.4 F (38 C). Urine output of 120 ml in 8 hours. Hemoglobin of 9.6 grams/dl. Pulse oximeter 91% on room air.

Urine output of 120 ml in 8 hours. Rationale Potassium is normally excreted in the urine, so low urine output (less than 30 ml/hour) should be reported to the healthcare provider (HCP) before giving addition potassium in an IV. The PN should ask the HCP for a prescription to obtain a serum electrolyte level to check the potassium, along with a prescription to check the BUN and creatinine level.

A client with a possible mumps infection is admitted to an acute care facility. Which infection control precaution should the practical nurse (PN) implement? Wear a mask or respirator within 3 feet of the client. Don a gown prior to entering the room. Move the client to a negative airflow room. Use only dedicated bedside equipment for care.

Wear a mask or respirator within 3 feet of the client. Rationale Droplet precautions should be implemented for a probable diagnosis of mumps, so mask or respirator should be used.

The practical nurse (PN) is assisting a client with an ileostomy appliance to shower. Which personal protective equipment (PPE) must the PN use? 1. Gown. 2. Gloves. 3. Mask. 4. Eye shield 5. Shoe covers.

1. gown 2. gloves 4. eye shield 5. shoe covers Rationale Gown, gloves, eye shield, and shoe covers are to be worn to provide protection because of the likelihood of exposure to bodily fluids. A mask is not needed because the client is not on droplet or airborne precautions.

A client is receiving a Mantoux test for tuberculosis screening. Which angle should the practical nurse (PN) insert the needle for injection? 15 degrees. 30 degrees. 45 degrees. 90 degrees.

15 degrees. Rationale The Mantoux test is an intradermal (ID) injection, so the angle of needle insertion is 5 to 15 degrees, which deposits the antigen into the dermis. Depending upon the client's amount of adipose tissue, other angles may place the medication into subcutaneous or intramuscular tissues, which does not provide the best results for ID testing.

The practical nurse (PN) is preparing to give a complete bed bath to an unconscious client. After implementing standard precautions before the procedure, what action should the PN implement next? 1.Wear protective gloves while providing perineal and perianal care. 2. Begin with a back wash and rub to assess for pressure areas over the sacrum. 3. Change the water after washing the client's face, and again after washing the back. 4. Wash each eye with a fresh area of a washcloth before washing the rest of the face.

4. Wash each eye with a fresh area of a washcloth before washing the rest of the face. Rationale The bed bathing procedure should begin and proceed from the cleanest to dirtiest areas. First, the eyes should be washed with a fresh washcloth with water only, no soap before proceeding to rest of the face. This is done in this order, so the eyes are not contaminated from the washcloth being soiled from the facial washing.

Which factors influence how the practical nurse (PN) obtains vital signs on a client? (Select all that apply.) Select all that apply Client height 5 feet 6 inches, weight 240 pounds (109 kg). History of right radical mastectomy two years ago. Daily use of oral digoxin (Lanoxin). NPO status of 12 hours for fasting blood test. Nasal congestion related to a "cold".

Client height 5 feet 6 inches, weight 240 pounds (109 kg). History of right radical mastectomy two years ago. Daily use of oral digoxin (Lanoxin). Rationale An overweight client often needs a large-sized blood pressure cuff to obtain their blood pressure accurately. Previous surgical procedures, such as a mastectomy or arteriovenous (AV) fistula on a particular side of the body, determines that the extremity on the affected side should not be used for blood pressure measurement. An apical pulse should be taken prior to the administration of a cardiovascular drug, such as digoxin which can accumulate to a toxic level that causes bradycardia and is not administered and healthcare provider notified, if apical pulse is below 60 beats per minute.

The practical nurse (PN) is caring for an older client who is receiving oxygen 4 L per nasal cannula. Which finding indicates a therapeutic response? Capillary refill less than 3 seconds. Respiratory rate 18 breaths/minute. Left and right lungs clear on auscultation. Client oriented to time and place.

Client oriented to time and place. Rationale In the elderly, cerebral oxygenation is best evaluated by level of sensorium. A therapeutic response to supplemental oxygen in the older client is manifested as orientation to person, time, and place.

Which client group is most likely to experience a therapeutic response from therapeutic touch? Pregnant women. Premature infants. Clients with psychoses. Clients with headaches.

Clients with headaches. Rationale Studies have found that therapeutic touch is most effective in reducing headache pain. Clients, such as pregnant women and premature infants, who are sensitive to energy repatterning and may need to avoid therapeutic touch. Persons who are sensitive to human interaction and touch, such as victims of physically abused or psychotic disorders, may misinterpret the intent of the treatment and may feel threatened and anxious by the treatment.

A client whose diet is low in fiber is at risk for which condition? Hip fracture. Diarrhea. Confusion. Colon cancer.

Colon cancer. Rationale Fiber speeds the movement of substances through the GI tract, reducing the amount of time the colon absorbs water and its exposure to digestive end-products that may be carcinogenic. Low-fiber diets increase the risk for constipation and colon cancer.

The practical nurse (PN) is calculating a client's fluid balance for the past 24 hours. The client had a total of 895 mL of IV fluid; 150 mL antibiotic IV; 16 ounces of water; two 4 ounce containers of gelatin; and one cup of creamy potato soup. The client voided 480 mL, 300 mL and 500 mL; vomited 300 mL and 175 mL. How many mL of positive fluid balance should be entered in the client's electronic medical record? (Enter numeric value only.)

Correct 250 Rationale Total intake includes: (IV fluid 895mL) + (IV antibiotic 150mL) + (16 ounces of water = 480mL) + (2 containers of gelatin = 240mL) + (1 cup soup= 240mL) = 1775 mL input Total output: (voided: 480 +300+ 500 = 1280 mL) + (vomited: 300 +175 = 475mL) = 1755 mL output 1775- 1755 = 250mL

A client who is three days postoperative complains of having "really bad pain" and wants medication now. What action should the practical nurse (PN) implement? Ask if the previous dose provided any relief. Encourage the use of relaxation breathing. Determine the location of the pain. Review the client's medical record.

Determine the location of the pain. Rationale To select the best prescribed analgesic, the PN should complete an assessment of the characteristics of the client's pain such as place (location), quality, radiation, severity, onset (PQRST) should be obtained.

An older client who has been on bed rest is not eating well and is exhibiting abdominal distension, cramping, and is passing small amounts of liquid stool. Which prescribed action is most important for the practical nurse (PN) to implement? Place incontinent pads on the bed. Give a PRN dose of a stool softener. Digitally remove a fecal impaction. Administer a soap suds enema.

Digitally remove a fecal impaction. Rationale Abdominal distension, cramping, and passage of small amounts of liquid stool are signs and symptoms of fecal impaction, which is relieved by digital removal.

When irrigating the eyes of a client, which action should the practical nurse implement? Instill the irrigant solution in the center of the eye so it flows out both sides of the eye. Direct the irrigation flow from the inner canthus to the outer canthus of the affected eye. Massage the irrigation fluid over the anterior surface of the eye using the upper eyelid. Instruct the client to blink repeatedly as the irrigant is place in the conjunctiva sac.

Direct the irrigation flow from the inner canthus to the outer canthus of the affected eye. Rationale Directing the flow from the inner canthus to the outer canthus allows irrigation of the greatest area of the eye surface as the client lies on the affected side, which moves the fluid by gravity and away from the nasolacrimal duct.

A client who is 8 hours postoperative begins using the incentive spirometer (IS) with 750 ml inspiratory volume and coughs up a large, thick, light yellow-white mucous plug. Which action should the practical nurse (PN) take? Document the findings. Instruct client to use less inspiratory force. Request bronchodilator nebulizing treatment. Obtain client's temperature.

Document the findings. Rationale The purpose of the incentive spirometer is to open alveoli and stimulate coughing to expectorate stagnant, thickened mucus that commonly pools postoperatively, so the implementation of IS is achieving its designated purpose, which should be documented.

Which action should the practical nurse (PN) take for a client whose serum sodium level is 159 mEq/L? Give sodium polystyrene (Kayexalate). Decrease high sodium foods in diet. Monitor for symptoms of cardiac distress. Encourage fluid intake of 2500 ml daily.

Encourage fluid intake of 2500 ml daily. Rationale The client is hypernatremic (normal range 136 to 145 mEq/L). Serum sodium imbalance is best corrected with fluid management, so fluid intake should be encouraged.

The practical nurse (PN) obtains an irregular pulse rate of 102 beats/minute for a client with a history of cardiac disease. Which action is most important for the PN to implement? Take client's blood pressure lying and standing. Record findings in the electronic medical record. Listen to the apical rate for one full minute. Take the radial pulse rate on the other wrist.

Listen to the apical rate for one full minute. Rationale To obtain the most accurate assessment of the heart rate, an apical heart rate should be obtained for one full minute when the radial pulse is irregular.

The practical nurse (PN) is reviewing laboratory results in the client's electronic medical record. Which lab value may indicate a state of malnutrition? Low level of sodium. Low level of albumin. Low level of hemoglobin. Low level of magnesium.

Low level of albumin. Rationale Low level of albumin may indicate malnutrition.

The practical nurse (PN) is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. What nursing action should the PN take? Reinforce the dressing with clean gauze sponges and tape. Change the surgical dressing immediately to prevent infection. Mark the outlined area of drainage with date, time and initials. Collect a sample of the drainage for a culture and sensitivity.

Mark the outlined area of drainage with date, time and initials. Rationale The area of bleeding on the dressing should be outlined, dated, timed and initialed for furture comparison and evaluation.

A client has an automatic blood pressure cuff on the right arm where an intravenous (IV) is infusing. In the left arm, a saline lock is present. The practical nurse (PN) notes the presence of blood in the IV infusion line. What action should the PN implement? Discontinue the intravenous infusion. Pause the infusion to take the blood pressure. Move the blood pressure cuff to the left arm. Ask the charge nurse to move the infusion site.

Move the blood pressure cuff to the left arm. Rationale When the blood pressure cuff inflates, blood flow backs up into the intravenous infusion line, so the PN should move the cuff to the left arm with the saline lock.

A client presents to the emergent care center reporting chest pain and feeling "lightheaded," as if he is "going to faint." What is the most important action the practical nurse (PN) should implement? Place client in a chair or upright on a stretcher. Obtain orthostatic blood pressure readings. Attach cardiac monitor electrodes on the client's chest. Give oxygen at 2 liters per nasal cannula.

Place client in a chair or upright on a stretcher. Rationale The client is at risk for sudden loss of consciousness and the client should first be positioned in a chair or place on a stretcher to prevent injury from fainting.

A client's serum potassium level is 2.9 mEq/L. Which is the most important finding that the practical nurse (PN) should report to the charge nurse? Bowel sounds hypoactive. Mental confusion noted. Urine copious and clear yellow. Pulse rate weak and irregular.

Pulse rate weak and irregular. Rationale Low serum potassium levels (normal 136 to 145 mEq/L) causes hypoactivity of cardiac muscle cells, thus a decrease cardiac output, resulting in a weak, irregular pulse. These finding is most important in evaluating perfusion and should be reported immediately.

A client who is demonstrating violent behavior is restrained by personnel using a 4-man maneuver. Two days later, the practical nurse (PN) sees that the client's arm is ecchymotic and mottled. What finding is most important for the PN to document? Radial pulse. Measurement of bruise size. Ability to touch fingers to thumb. Affected arm's range of motion.

Radial pulse. Rationale Neurovascular assessment includes monitoring the client's 7 Ps: Pulselessness, paresthesia, paralysis, polar temperature, pallor, puffiness, and pain. Obtaining a radial pulse evaluates blood flow and determines adequate neurovascular integrity to the injured extremity from the use of the restraint.

The practical nurse (PN) is calculating an 8-hour intake for a postoperative client. Based on the client's bedside record, how many ml of intake should the PN enter in the client's electronic record? (Enter numeric value only.)One cup of coffee One 8-ounce glass of iced tea One 6-ounce dish of flavored gelatin One-half cup of chicken broth

Rationale 30 ml = 1 ounce (oz), and 1 cup = 8 oz Coffee = 30 ml : 1 oz :: X ml : 8 oz = X = 30 x 8 = 240 ml Iced tea = 30 ml : 1 oz :: X ml : 8 oz = X = 30 x 8 = 240 ml Gelatin = 30 ml : 1 oz :: X ml : 6 oz = X = 30 x 6 = 180 ml Chicken broth = 1/2 cup equals 4 oz; 30 ml : 1 oz :: X ml : 4 oz = X = 30 x 4 = 120 ml Total intake = 240+240+180+120 = 780 ml

Acetaminophen is prescribed for an unconscious client with a temperature of 104oF (40oC). Which route should the practical nurse (PN) plan to administer this medication? Oral. Rectal. Buccal. Topical.

Rectal. Rationale The rectal route ensures absorption and safety for an unconscious client who is at risk for aspiration. Oral and buccal routes are contraindicated for an unconscious client who may have a compromised gag reflex and who is unable to swallow. Topical is not a common route of administration for acetaminophen.

A client who is placed in wrist protective devices begins to complain of pain and swelling in one hand. The practical nurse (PN) notes that both hands are cool and pale. What action should the PN implement? Remove both devices and notify the healthcare provider. Reassure the client and provide pain medication. Release and reapply the device on the side that is painful. Document observations and re-check in 15 minutes.

Remove both devices and notify the healthcare provider. Rationale Pain and swelling in one hand and cool and paleness of both hands are indications that circulation has been impaired, and both protective wrist devices should be removed immediately followed by notifying the healthcare provider.

The healthcare provider prescribes a vest restraint for an older male resident in a long-term facility who frequently falls out of his wheelchair. Which action should the practical nurse (PN) implement? Ambulate the client every 4 hours to the bathroom. Remove device every 2 hours and change client's position. Check with nursing supervisor about legal use of the restraint. Apply device loosely to prevent circulation impairment.

Remove device every 2 hours and change client's position. Rationale To prevent tissue perfusion complications, such as skin breakdown or compromised circulation, the PN should remove the device every 2 hours, provide the client position changes, and assess the client's need for continued use of the restraint.

An unlicensed assistive personnel (UAP) tells the practical nurse (PN) that another nurse on the unit is acting disrespectfully. What action should the PN implement? Report the complaint to the nurse-manager. Tell the UAP to share feelings with the nurse. Confront nurse about an anonymous staff member's complaint. Remind the staff that each member of the team is valuable.

Tell the UAP to share feelings with the nurse. Rationale Conflict resolution should first involve a one-on-one confrontation of the individuals in the situation, so the individuals involved in the conflict can be aware there is a problem. By expressing their feelings and perceptions about the situation, may be the first step in resolving the conflict.

Which factor is most likely to contribute to the development of osteoarthritis? 1. Atrophy of skeletal muscles. 2. Calcium deficiency. 3. High body mass index. 4. Sedentary lifestyle.

3. High body mass index. Rationale Increased weight causes joint changes. For each pound of weight (0.45KG) there is four pounds (1.8KG) of pressure on the body's weight bearing joints.

A male client who walks into the clinic begins talking with slurred speech to the practical nurse (PN). Which action should the PN implement first? 1. Ask the client how he is feeling today. 2. Perform the Stroke Assessment Scale. 3. Check the blood pressure for hypertension. 4. Obtain the client's fingerstick glucose level.

1. Ask the client how he is feeling today. Rationale The client is the best source of information about what is happening in his life and with his health, so a general statement of assessment should be made first. Further information should be obtained to determine if the client's speech suggests stroke or glucose abnormalities.

What should the practical nurse (PN) do to demonstrate proper body mechanics when assisting a client to a standing position from a sitting position? 1. Rock their own body weight as they pull the client up towards them. 2. Keep their own knees locked as they lift the client in a smooth motion. 3. Stand in front of the client, move their own feet apart and bend at the knees. 4. While standing behind the client, secure their own arms around the client's chest and lift upward. 5. Assess the client and determine whether or not another care provider is needed to assist.

1. Rock their own body weight as they pull the client up towards them. 3. Stand in front of the client, move their own feet apart and bend at the knees. 5. Assess the client and determine whether or not another care provider is needed to assist. Rationale Pulling is easier than lifting and the momentum by rocking the nurse's body uses that body weight to enhance the force of arm muscles. Moving feet apart widens the base of support and bending knees lowers the center of gravity. These actions are elements of safe body mechanics. When possible, use teams to lift clients ast is decreases the incidences of lower back injuries in healthcare workers and is safer for the client.

At 0900, a client's blood pressure is 120/70. At noon, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 200/100. Which action should the practical nurse (PN) implement first? 1. Take client's blood pressure. 2. Review previous vital signs. 3. Check for PRN medications. 4. Notify the healthcare provider.

1. Take client's blood pressure. Rationale This blood pressure reading is a significant change that should be verified first by the PN, and then a client assessment for other related symptoms. Reviewing the client's record may be helpful in identifying vital signs trends and previous elevations in blood pressure, but the priority is further assessment.

The practical nurse (PN) is preparing to change the abdominal dressing for a client who had abdominal surgery yesterday. When should the PN reinforce teaching about the client's dressing change? 1. The morning of the discharge. 2. During this dressing change. 3. The second postoperative day. 4. On day the surgery occurs.

2. During this dressing change. Rationale Reinforcement of teaching should be provided as soon as possible after identifying the client's need to learn self care. This dressing change provides the best time to demonstrate, explain the dressing change, and allow time for the client to ask questions and do a guided return demonstration.

Which signs or symptoms from a practical nursing (PN) assessment suggest a client is experiencing a form of stress? 1. Euphoria. 2. Diarrhea. 3. Headaches. 4. Palpitations. 5. Hypotension.

2. Diarrhea. 3. Headaches. 4. Palpitations. Rationale Diarrhea, palpitations, and headaches suggest the client may be experiencing stress due to normal physiologic responses to physical or emotional stress. Other options are not typically associate with the stress response.

What findings should the practical nurse (PN) document to describe infiltration at a client's intravenous (IV) site? 1. Infusion pump occlusion alarm noted. 2. Edema and cool skin at insertion site. 3. Blood backflow present in IV tubing. 4. Client states insertion site is painful.

2. Edema and cool skin at insertion site. Rationale Infiltration of IV solution in the subcutaneous tissues is best described by documenting what is present at the insertion site such as redness, swelling or edema and/or cool skin to touch.

A client who is three days postoperative complains of having "really bad pain" and wants medication now. What action should the practical nurse (PN) implement? 1. Ask if the previous dose provided any relief. 2. Encourage the use of relaxation breathing. 3. Determine the location of the pain. 4. Review the client's medical record.

3. Determine the location of the pain. Rationale To select the best prescribed analgesic, the PN should complete an assessment of the characteristics of the client's pain such as place (location), quality, radiation, severity, onset (PQRST) should be obtained.

Which action by another nurse should the practical nurse (PN) report as a breach of client confidentiality? 1. A client who is in the hallway is told that the charge nurse called the healthcare provider. 2. A color-coded "risk for a fall" wristband is placed on an elderly client. 3. Visitors are told to wear a mask because the client has tuberculosis. 4. The healthcare provider is notified that illegal drugs were found in a client's possession.

3. Visitors are told to wear a mask because the client has tuberculosis. Rationale Discussion of a client's diagnosis with visitors is a violation of the client's Health Information Privacy.

The practical nurse (PN) is administering medications to several clients. Which client requires immediate action by the PN? 1. An older female who is having difficulty swallowing. 2. An older male who states he is tired of taking pills. 3. A female client who reports the onset of a rash. 4. A male client who states that his throat feels tight.

4. A male client who states that his throat feels tight. Rationale The client who is states that his throat feels tight may be experiencing closure of the airway, which is the priority, especially if this occurs after being administered medication because he may be experiencing an anaphylatic reaction to the medication.

The practical nurse (PN) identifies four assigned clients that need additional follow-up care. Which client issue has the highest priority? 1. Refuses a scheduled nebulizer treatment. 2. Requests pain medication for a headache. 3. Result of fasting glucose is 150 mg/dl. 4. Infiltrated intravenous secondary medication.

4. Infiltrated intravenous secondary medication. Rationale The cleint with the IV infiltration should be addressed first to reduce pain and subcutaneous tissue inflammation and damage from extravasation of the drug.

Which factors influence how the practical nurse (PN) obtains vital signs on a client? (Select all that apply.) Select all that apply Client height 5 feet 6 inches, weight 240 pounds (109 kg). History of right radical mastectomy two years ago. Daily use of oral digoxin (Lanoxin). NPO status of 12 hours for fasting blood test. Nasal congestion related to a "cold".

Client height 5 feet 6 inches, weight 240 pounds (109 kg). History of right radical mastectomy two years ago. Daily use of oral digoxin (Lanoxin). Rationale An overweight client often needs a large-sized blood pressure cuff to obtain their blood pressure accurately. Previous surgical procedures, such as a mastectomy or arteriovenous (AV) fistula on a particular side of the body, determines that the extremity on the affected side should not be used for blood pressure measurement. An apical pulse should be taken prior to the administration of a cardiovascular drug, such as digoxin which can accumulate to a toxic level that causes bradycardia and is not administered and healthcare provider notified, if apical pulse is below 60 beats per minute.

The practical nurse (PN) is obtaining a blood specimen from a client's peripherally inserted central catheter (PICC). What action should the PN to implement first? Transfer specimen using Vacutainer device. Discard first 5 ml of blood sample. Regulate the infusion rate as prescribed. Flush with 10 ml of normal saline.

Discard first 5 ml of blood sample. Rationale When obtaining blood specimens from a PICC line, discard the first 5 ml of blood, which clears the catheter of fluid and medication before obtaining a blood specimen for analysis is drawn.

Which technique is most important for the practical nurse to implement when obtaining a specimen for urinalysis, culture, and sensitivity for a male client? Direct client to void in toilet collect urine midstream in specimen cup. Label the sterile specimen container for culture, sensitivity, and urinalysis. Ensure client understands to retract the foreskin and cleanse meatus. Obtain the specimen at the next time the client has the urge to void.

Ensure client understands to retract the foreskin and cleanse meatus. Rationale An uncircumcised male client should be instructed to retract the foreskin and cleanse the urinary meatus with an antiseptic wipe to prevent contamination of the specimen from skin surfaces. Although midstream collection, proper labeling, and prompt collection of the specimen are important, it is most important to ensure the client implements to provide accurate analysis of the urine specimen.

Which technique should the practical nurse (PN) use to most accurately assess a client's baseline blood pressure during a routine health examination? Measure the pressure in each arm while the client sits with the arm supported at heart level. Calculate the average blood pressure using readings obtained in both arms. Obtain the blood pressure first with the client lying supine and then while standing. Take additional measurements for readings with a 10 mm Hg difference.

Measure the pressure in each arm while the client sits with the arm supported at heart level. Rationale The blood pressure should be taken initially in both arms while the client is seated or supine with the arm bared, supported, and positioned at the level of the heart. Accurate assessment of baseline blood pressure is best obtained with sequential readings at 2 minute intervals when there is a difference of 5 mm Hg.

The practical nurse (PN) is administering eye drops to a client with glaucoma. Which technique should the PN implement to ensure the eyes drops are effectively absorbed topically? 1. Tell the client to move closed eyes from side to side. 2. Retract the upper eyelid using the non-dominant hand. 3. Gently place the dropper tip on the conjunctival sac. 4. Place pressure at the outer canthus after instillation.

1. Tell the client to move closed eyes from side to side. Rationale Telling the client to move the closed eyes from side to side promotes even distribution of the medication without squeezing the medication out of the conjunctival sac. Placing pressure over the lacrimal duct in the inner canthus, prevents drainage of the drops into the nasolacrimal duct, thus prevents systemic absorption.

A client with a possible mumps infection is admitted to an acute care facility. Which infection control precaution should the practical nurse (PN) implement? 1. Wear a mask or respirator within 3 feet of the client. 2. Don a gown prior to entering the room. 3. Move the client to a negative airflow room. 4. Use only dedicated bedside equipment for care.

1. Wear a mask or respirator within 3 feet of the client. Rationale Droplet precautions should be implemented for a probable diagnosis of mumps, so mask or respirator should be used.

The practical nurse (PN) is working with a client who has increased intracranial pressure. What is the best position for this client? 1. Sims'. 2. Trendelenberg. 3. High Fowler's. 4. Dorsal recumbent.

3. High fowlers Rationale High Fowler's position will have the client supine at 90 degrees. This will help decrease intracranial pressure.

The practical nurse (PN) is documenting the administration of a client's medication. Which entry by the PN complies with The Joint Commission (TJC) g uidelines for use of abbreviations? MS 4.0 mg IM given for pain rated "8" on a scale of "0-10." Novolog insulin 4 u given SC in the right arm. Doses of clonidine 0.15 mg given AC BID. Oral liquid vitamin supplement changed from 2.0 cc to 3.00 cc qd.

Doses of clonidine 0.15 mg given AC BID. Rationale Recommendations from The Joint Commission (TJC) about the use of abbreviations with medication administration include using a zero to precede the decimal point in dosage such as 0.15 mg and do not exclude using AC (before meals) or BID (twice a day). The "Do Not Use" list from the TJC includes initials for drug names, trailing zeros, and the abbreviations u, SC, cc, and qd.

An older client arrives at the outpatient clinic complaining of burning and severe right-sided "chest pain." The practical nurse (PN) observes vesicular eruptions in a line across the anterior and posterior chest wall. What action should the PN implement? Obtain a culture of any drainage. Ask about recent food exposures. Inquire about recent foreign travel. Wear gloves during palpation.

Wear gloves during palpation. Rationale The client is manifesting signs of shingles, or Herpes zoster which can occur in clients who had chickenpox as a child, are experiencing stress, and have not received the Herpes immunization. Standard precautions should be observed with a client who has a herpetic vesicular rash. While a culture identifies the virus, the most important aspect during the focused assessment is contact precautions.

A client with Clostridium difficile is placed on isolation precautions. Which transmission-based precaution should the practical nurse implement? Don a particulate respirator mask when in the room. Wear gown and gloves when rendering direct care. Close the door to the private negative airflow room. Prevent the client from leaving the room without a mask.

Wear gown and gloves when rendering direct care. Rationale Contact precautions include the use of gown and gloves for all healthcare personnel in close contact with a client with the fecal infection caused by Clostridium difficile.

A client who was administered a medication ten minutes ago is now reporting a rash, itching, and a headache. What is the first action the practical nurse (PN) should take? 1. Evaluate the client's vital signs. 2. Immediately administer epinephrine. 3. Notify the healthcare provider "STAT". 4. Activate the emergency response system.

1. Evaluate the client's vital signs. Rationale Based on the presenting signs and symptoms the client appears to be experiencing a hypersensitivity reaction to the medication received. The PN needs to evaluate the client's vital signs to ensure the client is not becoming hypotensive and tachycardia which would be signs of impending anaphylaxis reaction to the medication.

The practical nurse (PN) is irrigating a client's wound. Which factors could delay wound healing as a result of wound irrigation? 1. The use of povidone-iodine solution. 2. Hydrogen peroxide poured into wound. 3. Normal saline used as an irrigation fluid. 4. Direct force of irrigation solution on wound bed. 5. Irrigation solutions cooler than room temperature.

1. The use of povidone-iodine solution. 2. Hydrogen peroxide poured into wound. 4. Direct force of irrigation solution on wound bed. 5. Irrigation solutions cooler than room temperature. Rationale Povidone-iodine and hydrogen peroxide although cytotoxic to bacteria, are harmful to cells needed for wound healing. Cold irrigation solutions decrease the activity of leukocytes needed for wound healing. Too much force on wound bed will disrupts newly formed, fragile tissue in wound bed.

Which questions are best for the practical nurse (PN) to ask to assess for "disuse syndrome" in clients diagnosed with neuromuscular diseases such as muscular dystrophy or multiple sclerosis? 1. What is included in a typical day for you? 2. Do you feel you are financially stable? 3. In what part of town is your home located? 4. How much assistance do you need to move around? 5. On a scale 1-10, how would you rate overall pain level?

1. What is included in a typical day for you? 4. How much assistance do you need to move around? 5. On a scale 1-10, how would you rate overall pain level? Rationale These questions are open-ended and will give insight to the client's activity level throughout the day and eating habits; whether or not their living environment is adaptive and supportive; and their perception of discomfort. The mnemonic "ABCDE", stands for age, body weight, chronic illness, discomfort, and environment is an easy way to remember risk factors for "disuse syndrome".

The practical nurse (PN) is giving iron dextran (Imferon) 250 mg IM using the Z-track method to a client with anemia. Which needle should the PN select for this injection? 2-inch, 19 gauge needle. inch, 23 gauge needle. 1-inch, 18 gauge needle. 1 inch, 16 gauge needle.

2-inch, 19 gauge needle. Rationale When administering iron dextran (Imferon) IM using the Z-tract method, a 2-inch, 19 gauge needle should be selected to ensure the tissue-irritating medication is placed deep into the muscle and cannot leak through the needle tracks.

Which practical nursing (PN) tasks would be appropriate for the PN to assign to the unlicensed assistive personnel (UAP)? 1. Performing venipuncture for serum CBC, electrolytes and blood cultures. 2. Assisting clients with morning ADLs to include showering and shaving. 3. Transporting a client with a fractured wrist to the cast clinic for cast placement. 4. Placing a urinary indwelling catheter prior to a procedure. Assessing breath sounds of a client on admission to the asthma clinic.

2. Assisting clients with morning ADLs to include showering and shaving. 4. Transporting a client with a fractured wrist to the cast clinic for cast placement. Rationale Assisting clients with activiites of daily living and with transporting stable clients are within the scope of practice for a UAP.

The practical nurse (PN) is assigned the PM care of six clients on a medical surgical unit whose morning laboratory results are not available. What action should the PN take? 1. Ask the clients if a laboratory technician collected blood today. 2. Call the laboratory to ask if the clients' test results are ready. 3. Ask the healthcare provider if the blood results were reported. 4. Collect additional blood specimens and deliver to the laboratory.

2. Call the laboratory to ask if the clients' test results are ready. Rationale The PN should call the laboratory to determine if the specimens has been collected, analyzed, and ready to be reported to the healthcare provider.

A client diagnosed with an incurable terminal disease states "If I adjust my work schedule, eat better and exercise more, I will be able to reverse the disease process and become disease-free". The practical nurse (PN) recognizes that this client is exhibiting which stage of grief as described by Kubler-Ross? 1. Anger. 2. Denial. 3. Bargaining. 4. Acceptance.

2. Denial. Rationale The client is exhibiting denial. The change in life style may slow down the disease, but it will not cure it.

The practical nurse (PN) is obtaining a blood specimen from a client's peripherally inserted central catheter (PICC). What action should the PN to implement first? 1. Transfer specimen using Vacutainer device. 2. Discard first 5 ml of blood sample. 3. Regulate the infusion rate as prescribed. 4. Flush with 10 ml of normal saline.

2. Discard first 5 ml of blood sample. Rationale When obtaining blood specimens from a PICC line, discard the first 5 ml of blood, which clears the catheter of fluid and medication before obtaining a blood specimen for analysis is drawn.

A client has a swollen, bruised, sprained ankle and states that the current pain level has risen from a 3 to a 5 on a 10 point scale. Which analgesic medication would most likely be prescribed to relieve this pain? 1. Morphine. 2. Ibuprofen. 3. Oxycodone. 4. Acetaminophen.

2. Ibuprofen. Rationale Ibuprofen is indicated for mild to moderate pain relief. It is also a non-steroidal anti-inflammatory drug (NSAID) which inhibits the synthesis of prostaglandins which then inhibits the cellular response to inflammation.

Which equipment malfunction should the practical nurse (PN) report as having the highest risk to client safety? 1. Electronic thermometer does not register a temperature. 2. Intravenous pump screen does not light up when turned on. 3. Gauges on a tank do not move when regulator is attached. 4. Fingerstick glucose monitor reads "quality control required."

2. Intravenous pump screen does not light up when turned on. Rationale Failure of the IV pump screen to light up indicates an internal failure, so the priority is to obtain a new pump to ensure IV access is maintained, and fluids and medications can be given to the client safely.

A client who is two days postoperative for a colectomy and temporary colostomy tells the practical nurse (PN) that the drainage bag is full of gas. What action should the PN take? 1. Assess the client for signs of intestinal obstruction. 2. Open the bag's clamp to release the flatus. 3. Administer a PRN dose of simethicone (Mylicon). 4. Change the bag to determine character of output.

2. Open the bag's clamp to release the flatus. Rationale In the course of healing with a temporary colostomy, the first sign of return of peristalsis is the passage of flatus, which will distend the colostomy bag, so the first action is open the clamp on the drainage bag to release the flatus. The flatus is a positive sign of peristalsis, which indicates there is no obstruction.

Which disposable product should the practical nurse place in a biohazard container? 1. Used tissue with sputum from a client with bacterial pneumonia. 2. Peri-pads saturated with rubra lochia for a client who is one day post-vaginal delivery. 3. An empty IV bag from a client with human immunosuppressive virus (HIV). 4. A discontinued urinary drainage bag that is full of urine from a client with Hepatitis B.

2. Peri-pads saturated with rubra lochia for a client who is one day post-vaginal delivery. Rationale Bloody discharge on peri-pads, which can transmit blood-borne diseases, should be disposed in biohazard containers.

The practical nurse is administering otic drops to an adult client with otitis externa. Which action describes the correct administration technique? 1. Manipulate the ear lobe back and down. 2. Pull the pinna of the ear up and out. 3. Apply drops to a cotton-tipped applicator for insertion. 4. Administer the drops at a cool room temperature.

2. Pull the pinna of the ear up and out. Rationale The adult ear canal should be straightened by pulling upward and outward on the pinna prior to instilling ear drops which allows the topical agent to reach the deeper ear structures.

The practical nurse (PN) is preparing to reinforce information with a client who has chronic pain. Which learning objective should the PN review? 1. Understands the use of herbal treatment options. 2. Recalls two nonpharmacological interventions used to relieve pain. 3. States the value of using several pain management approaches. 4. Discusses the dangers of prescriptive drug abuse.

2. Recalls two nonpharmacological interventions used to relieve pain. Rationale A measurable objective is the client is able recall two of the nonpharmacological interventions.

A client with Clostridium difficile is placed on isolation precautions. Which transmission-based precaution should the practical nurse implement? 1. Don a particulate respirator mask when in the room. 2. Wear gown and gloves when rendering direct care. 3. Close the door to the private negative airflow room. 4. Prevent the client from leaving the room without a mask.

2. Wear gown and gloves when rendering direct care. Rationale Contact precautions include the use of gown and gloves for all healthcare personnel in close contact with a client with the fecal infection caused by Clostridium difficile.

An older client is receiving normal saline at 83 ml/hour per gravity. At the end-of-shift assessments, the practical nurse (PN) calculates the client's intake and output and determines that the infusion delivered 500 ml in the last hour. Which action should the PN take first? 1. Assess the lower extremities for pitting edema. 2. Auscultate the lungs for crackles. 3. Notify the healthcare provider. 4. Check the amount of urinary output.

2.Auscultate the lungs for crackles. Rationale The client's response to the fluid overload incident is the first concern, so the PN should auscultate the client's lungs for crackles to determine if the client is experiencing fluid overload. The incident of the IV fluid infusion error, client's pulmonary assessment findings and client's overall response to the infusion volume should then be reported to the healthcare provider.

When should the practical nurse (PN) reinforce teaching to a client about a daily surgical dressing change? 1. First 24 hours after surgery. 2. The day client is discharged. 3. In the morning after a.m. care. 4. During the next dressing change.

4. During the next dressing change. Rationale Reinforcement of teaching should be provided as soon as possible after identification of the client's need to learn self care. The next dressing change provides the best time to demonstrate, explain the dressing change, and allow the client to perform a return demonstration of the dressing change.

The practical nurse (PN) notifies the healthcare provider that a male client has become combative and needs a protective device to prevent injury to self and others. Which principle should the PN use when selecting a protective device? 1. A protective device must be applied by qualified personnel. 2. A restraining device is provided for behavioral use only. 3. A protective device provides the least amount of immobilization. 4. A restraining device ensures modification of unsafe client behavior.

3. A protective device provides the least amount of immobilization. Rationale The use of restraints is set by federal law and The Joint Commission (TJC) standards that ensure all clients have the right to be free from seclusion and physical or chemical restraints, except to ensure the client's and other's safety. The use of protective or restraining devices must include documentation of the restrictive interventions causing the least limited mobility and scheduled follow-up assessments. The need for a restraint must be assessed, reviewed and if deemed necessary, a prescription must be obtained every 24 hours for continuance of the restraint.

A client with a forearm laceration arrives in the clinic applying direct pressure with a clean washcloth. The practical nurse (PN) notes that the washcloth is saturated with blood. What action should the PN implement? 1. Remove the saturated dressing and apply a new one. 2. Place a new dressing on top of the saturated one. 3. Apply digital pressure to arm above the injury. 4. Place an ice pack over the dressed wound.

3. Apply digital pressure to arm above the injury. Rationale Lacerations of an extremity that continue to bleed with direct pressure may indicate that underlying blood vessels are severed. Additional pressure to the arm or pulse point above the laceration should be applied until further treatment can be provided

The wife of an older, overweight man tells the practical nurse (PN) that her husband snores and frequently wakes up jerking or gasping. What action should the PN take? 1. Encourage the use of 3 pillows to prevent orthopnea. 2. Recommend a home nebulizer if he wheezes. 3. Discuss the possibility of a sleep study for sleep apnea. 4. Explain common physiological changes related to aging.

3. Discuss the possibility of a sleep study for sleep apnea. Rationale The wife is describing common signs of obstructive sleep apnea, so the need for a sleep study for her husband should be discussed to determine if he is a candidate for bi-level positive airway pressure (BiPAP) therapy.

The practical nurse (PN) is reinforcing self-care with a male client who is being discharged with an ileostomy. Which client behavior best indicates to the PN that he understands ileostomy care? 1. Affirms his understanding of the process and has no more questions. 2. States that liquid stools will be reported to the healthcare provider. 3. Empties the ileostomy appliance bag when it is about one-third full. 4. Cuts the skin barrier wafer opening 1/2 inch smaller than the stoma.

3. Empties the ileostomy appliance bag when it is about one-third full. Rationale The drainage appliance should be emptied or changed when it is one-fourth to one-third full of effluent to prevent the weight of the liquid feces from disrupting the seal of the drainage appliance bag to the skin surrounding the stoma. The best evaluation of understanding of this concept is the client performing a return demonstration.

Which practical nursing (PN) actions are required when performing a transcutaneous electrical nerve stimulation (TENS) procedure with a client? 1. Place clients with pacemakers on cardiac monitors during procedure. 2. To avoid trauma, do not place the electrodes over or near injury site. Correct 3. Instruct the client to adjust the intensity of TENS stimulation for pain relief. 4. Ensure and review there is a healthcare provider's prescription for the TENS. 5. Remove any hair or lotions from the skin where the electrodes are to be placed.

3. Instruct the client to adjust the intensity of TENS stimulation for pain relief. 5. Remove any hair or lotions from the skin where the electrodes are to be placed. Rationale TENS procedure requires a healthcare provider's prescription. Anything that could interfere with the electrical current pathway needs to be remove from the skin. The client is to adjust the intensity of the current until pain relief is achieved. Clients with pacemakers or arrhythmias are never to use TENS.

The practical nurse (PN) is checking client care equipment in the clinic for proper functionality. Which finding should the PN identify as a piece of equipment in need of repair? 1. Pulse oximeter shows "no pulse detected". 2. Glucometer consistently reading "lo". 3. Intravenous pump alarms constantly. 4. Blood pressure cuff pops off during inflation.

3. Intravenous pump alarms constantly. Rationale A constant alarming infusion pump usually indicates an internal error that requires repair of the electronic functions and the equipment needs pull out of use and sent for repair.

The practical nurse (PN) is assessing a client and obtains a pulse rate of 120 beats/minute, respirations of 28 breaths/minute, and a blood pressure of 80/60. Which action should the PN take first? 1. Determine the client's orientation status. 2. Encourage client to take slow deep breaths. 3. Position the client flat in the bed. 4. Measure the client's SpO2 using a pulse oximeter.

3. Position the client flat in the bed. Rationale The client is hypotensive, so the first action is to place the client's head of the bed flat to increase cerebral circulation. Based on the client's vital signs, the client's orientation status should be evaluated next.

The practical nurse (PN) is reviewing the electronic medication administration record (MAR) for a client who receives warfarin (Coumadin) daily. A notation on the MAR for yesterday is marked "hold" for the daily Coumadin dose and no other directions are noted for today's dose. What action should the PN take? 1. Withhold the medication. 2. Call the pharmacist. 3. Administer the drug. 4. Check the prescription.

4. Check the prescription. Rationale Any medication on the MAR that lacks clarity should be resolved by checking the original prescription first. This is particularly true in a case where the original prescription on a long-term medication was modified without clear direction of what should be done next. If there is still confusion, the prescribing healthcare provider should be contacted.

Which client group is most likely to experience a therapeutic response from therapeutic touch? 1. Pregnant women. 2. Premature infants. 3. Clients with psychoses. 4. Clients with headaches.

4. Clients with headaches. Rationale Studies have found that therapeutic touch is most effective in reducing headache pain. Clients, such as pregnant women and premature infants, who are sensitive to energy repatterning and may need to avoid therapeutic touch. Persons who are sensitive to human interaction and touch, such as victims of physically abused or psychotic disorders, may misinterpret the intent of the treatment and may feel threatened and anxious by the treatment.

Which action should the practical nurse (PN) take for a client whose serum sodium level is 159 mEq/L? 1. Give sodium polystyrene (Kayexalate). 2. Decrease high sodium foods in diet. 3. Monitor for symptoms of cardiac distress. 4. Encourage fluid intake of 2500 ml daily.

4. Encourage fluid intake of 2500 ml daily. Rationale The client is hypernatremic (normal range 136 to 145 mEq/L). Serum sodium imbalance is best corrected with fluid management, so fluid intake should be encouraged.

A male client with coffee ground emesis is admitted with a hemoglobin of 10.2 grams that is now 7.5 grams/dl since admission. The client's blood is typed and crossmatched for 2 units of blood, and the healthcare provider prescribes STAT administration of one unit. The client indicates to the practical nurse (PN) that he wants to shower first. Which intervention should the PN implement? 1. Allow the client to do hygienic care first at the bedside. 2. Let the client sponge in the bathroom with assistance. 3. Permit the client to shower with assistance as requested. 4. Explain the need for starting the transfusion immediately.

4. Explain the need for starting the transfusion immediately. Rationale The client's hemoglobin indicates active bleeding, and the PN should explain the need for immediate blood transfusion administration to prevent the client going into shock. Once the transfusion is in progress, the client may be offered hygiene grooming as tolerated.

The practical nurse (PN) finds an older female client lying on the floor. What action should the PN take first? 1. Inquire if the client has any pain. 2. Assist the client back to bed. 3. Ask the client why she got up. 4. Obtain the client's vital signs.

4. Obtain the client's vital signs. Rationale The first action is to determine if the client's vital signs are stable or if there is an indication of a cardiovascular event that may have contributed to the client's fall. After assessing the client for injuries, determining if the client has pain should be implemented.

Which finding indicates to the practical nurse that the client is meeting the rehabilitation goals after an acute brain attack? 1. Turns head away from any painful stimuli. 2. Tolerates tube feedings with residuals under 50 ml. 3.Compensates by limiting use of affected extremity. 4. Puts hands on chair arms when standing to use a walker.

4. Puts hands on chair arms when standing to use a walker. Rationale Goals of rehabilitation include regaining function and independence in activities of daily living, such as mobility. Using the chair arm to stand up to use a walker is a safe use of an assistive device.

The practical nurse (PN) uses the SBAR format to report an acute client situation to the healthcare provider. Which information is the correct understanding of this method? 1. The "S" stands for safety and indicates any issues related to safety, such as restraints. 2. The "B" stands for bleeding and indicates any signs of hemorrhage. 3. The "A" stands for airway and reports on the client's airway status. 4. The "R" stands for recommendation and suggests an action for the healthcare provider.

4. The "R" stands for recommendation and suggests an action for the healthcare provider. Rationale Situation, Brief history, Assessment, Recommendation (SBAR), is a universal, standardized format that is recommended by The Joint Commission (TJC) to improve communication and enhance patient safety when reporting acute focused issues. SBAR is not a general report or head to toe assessment. The PN is expected to articulate a recommendation or request to the receiving healthcare provider regarding the acute client situation.

The practical nurse (PN) is caring for a client who begins to vomit copious amounts of blood. What action should the PN do first? 1. Insert nasogastric tube for gastric suctioning. 2. Report the client's vital signs to the healthcare provider. 3. Initiate an infusion of normal saline (NS). 4. Use a Yankauer-tip device for oropharyngeal suction.

4. Use a Yankauer-tip device for oropharyngeal suction. Rationale A client who is vomiting copious amounts of blood is at risk for aspiration, so oropharyngeal suctioning should be provided using a Yankauer-tip device which clears the airway with minimal mucosal trauma.

A client who has a tunneled Hickman catheter for hemodialysis receives a prescription for IV antibiotics. Which action should the practical nurse take? 1. Clean the port with hexacholorophene prior to access a Hickman catheter. 2. Use a 10 ml or larger syringe when accessing the port. 3. Reposition the client if resistance is felt when using a Hickman catheter. 4. Utilize a peripheral IV access to administer IV antibiotics.

4. Utilize a peripheral IV access to administer IV antibiotics. Rationale Catheters, such as a Hickman catheter, are used exclusively for hemodialysis unless a life-threatening situation occurs. A peripheral IV should be used for administration of the IV antibiotic.

While assessing an adult client, the practical nurse (PN) identifies generalized edema in the client's arms, legs, and periorbital regions. Which dietary influence could have contributed to this generalized edema? A diet high in carbohydrates. A diet high in glucose. A diet low in protein. A diet low in sodium. Rationale Proteins create great colloid osmotic pressure. If there is a protein deficiency, less fluid is reabsorbed by the capillaries and the fluid remains in the interstitial tissue causing the edema.

A diet low in protein. Rationale Proteins create great colloid osmotic pressure. If there is a protein deficiency, less fluid is reabsorbed by the capillaries and the fluid remains in the interstitial tissue causing the edema.

A client who is postoperative is receiving an infusion at 80 ml/hour. At the end of 8 postoperative hours, the practical nurse (PN) documents that the client tolerated 100 ml oral intake of ice chips, and urinary output is 1,100 ml. What action should the PN take? Document the intake and output findings. Check the client for dry mucous membranes. Obtain a prescription to increase the IV fluids. Monitor for signs of electrolyte imbalances.

Document the intake and output findings. Rationale At the end of the first 8 postoperative hours, the client's intake (total of 740 ml, 640 ml IV & 100 ml oral) and output (1,100 ml) should be documented. Although determining if the client needs additional oral fluids should be implemented, the client's fluid balance is adequate at this time.