HESI

A client has an oral intake during the previous 8 hours of the following: 2 cups coffee, 240 mL milk, ¾ cup applesauce, 1 liter water, 6 ounces fruit juice, and 3 ounces pudding. How many milliliters will the practical nurse (PN) record as the total 8-hour oral intake? (Fill in the blank. Type in numbers only as your answer and round to the nearest whole number.)

1900

The practical nurse (PN) is assisting with bathing an independent adult client who has a plaster cast on the right forearm. Which action should the PN implement to encourage self-care by the client?

Provide back care and foot care as needed.

A representative of the hospital's accrediting agency is performing an on-site visit at the hospital and asks to see the nurses' notes from a client's medical record. What action should the practical nurse (PN) take?

Provide the agency representative with the information from the client's medical record. A hospital's accreditation agency randomly selects clients and reviews the nursing care documentation to evaluate the standard of care being provided by the hospital. The practical nurse (PN) can provide the agency representative with the requested information.

A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the practical nurse (PN)?

Purulent sputum Steroids cause immunosuppression, and purulent sputum is an indication of infection, so this symptom is of greatest concern.

A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and tachypnea. What action should the practical nurse (PN) take first?

Raise the head of the bed. Raising the head of the bed facilitates respiratory functioning. The first action is that client should be placed in a semi-Fowler or Fowler position. Although tracheal deviation can occur with a tension pneumothorax, the client should be placed in an upright position in the bed before further assessment is obtained.

The practical nurse (PN) determines that a client's radial pulse is irregular. What action should the PN take next?

Take an apical pulse for 1 minute to verify irregularity.

The practical nurse (PN) is assessing several clients before surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?

Taking anticoagulants for the past year

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement should the practical nurse (PN) identify that best demonstrates the client's readiness to manage his/her wound care after discharge?

The client demonstrates the wound care procedure correctly.

Which client finding requires further action by the practical nurse (PN)?

The drainage tube of an indwelling catheter is looped below the client's bladder.

The practical nurse (PN) is counting a client's respiratory rate. During a 30-second interval, the PN counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the PN counts eight respirations. What respiratory rate should the PN document?

16

Which intervention is most important for the practical nurse (PN) to implement for a client who is experiencing urinary retention?

Assess for bladder distention.

The practical nurse (PN) enters a client's room and finds the client on the floor after a fall. How should the PN communicate this situation to the risk management team?

Submit a completed incident report describing the situation to the unit manager.

Which serum laboratory value should the practical nurse (PN) monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

sodium Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning.

A client receives a prescription for a 5-mg dose of a drug. The oral preparation of this drug is available as 3 mg/capsule. Which intervention should the practical nurse (PN) implement?

Call the health care provider about the prescribed dose.

The practical nurse (PN) is instructing a client in the proper use of a metered-dose inhaler. Which instructions should the PN reinforce to the client to ensure the optimal benefits from the drug?

Compress the inhaler while slowly breathing in through the mouth.

The practical nurse (PN) is administering medications to a client via a nasogastric tube. The 0900 medications include a sustained-release spansule. Which action should the PN take when administering the sustained-release drug via the nasogastric tube (NGT)?

Consult the health care provider for a different drug form that can be crushed.

A client's plan of care includes a nursing diagnosis of "Altered sleep patterns related to nocturia." Which client information is important for the practical nurse (PN) to provide?

Decrease your intake of fluids after the evening meal.

When performing sterile wound care in the acute care setting, the practical nurse (PN) obtains a bottle of normal saline from the bedside table that is labeled opened and is dated 48 hours before the current date. What is the best action for the PN to take?

Discard the saline solution and obtain a new and unopened bottle.

The practical nurse (PN) is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. What action should the PN take next?

Document that the client responded to a painful stimulus.

While morning care is being provided, a client becomes restless, agitated, and confused. The client's heart rate is elevated, and respiratory rate is 24 breaths/min. Which additional finding should the practical nurse (PN) identify as an early sign of hypoxia?

Elevated blood pressure The blood pressure becomes elevated during the early stages of hypoxia in an effort to increase perfusion to distal tissues. Respiratory changes related to hypoxia are increased rate and depth of respiration.

The practical nurse (PN) obtains lying and standing blood pressure measurements for a client who complains of dizziness upon standing up from the computer at work. The PN determines that systolic pressure decreases 24 mm Hg when standing. What intervention is most important for the PN to implement?

Encourage the client to flex both feet before rising slowly.

The practical nurse (PN) reinforces information with a client about portion control and diet management. Which portion description indicates that the client understands the instructions?

Four small cookies are about the size of four poker chips.

The practical nurse (PN) is assessing a client's 2 days status/posthip replacement surgery. In assessing the client's vital signs, which finding requires the most immediate action by the PN?

Hyperthermia Hyperthermia, an elevated body temperature, requires the most immediate action to determine the cause of the fever and contact the health care provider.

An elderly client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the practical nurse (PN) to consider before assisting this client?

Hypotension places the client at risk for falls because it can cause dizziness. To ensure client safety, it is most important for the PN to be aware of the client's low blood pressure before transfer.

When should the practical nurse (PN) evaluate the client's pain level? (Select all that apply.)

Routinely with measurement of vital signs When the client initially complains of pain At the beginning and end of each shift Thirty to 60 minutes after administration of an analgesic