hesi questions

What statement by the client should alert the practical nurse that immediate attention by the ophthalmologist is necessary? "I now see halos around lights." "I have yellow, watery drainage from my eye." "The center of my vision is blurry." "My vision has become increasingly cloudy this past year."

"I now see halos around lights." Acute angle-closure glaucoma is a sudden or rapid increase in pressure inside the eye, which can result in optic nerve damage and vision loss if untreated. Seeing halos around lights (A) is a classic symptom of acute angle-closure glaucoma, an emergency condition. Yellow, water drainage from the eye (B) is a classic symptom of conjunctivitis, central vision loss (C) is a classic symptom of macular degeneration, and increasingly cloudy vision over time (D) is a classic symptom of cataracts. Although (B, C, and D) require medical attention, they are not as critical as (A).

A client with epilepsy is having bilateral rhythmic jerking movements of all extremities. After calling for help, which action should the practical nurse (PN) do next? (Arrange the interventions from first to last.) 1 Maintain the client's airway. 2 Apply pads to the bedside rails. 3 Avoid stimulation during post-ictal phase. 4 Observe the client for incontinence.

1 Maintain the client's airway. 2 Apply pads to the bedside rails. 4 Observe the client for incontinence. 3 Avoid stimulation during post-ictal phase. During a tonic-clonic seizure (grand mal), the PN should maintain the client's airway. Next, the client should be protected from injury by padding the side rails. Observation of the client's behaviors, such as incontinence, should be noted during a seizure. Minimal stimulation should be maintained during the post-ictal phase to prevent precipitation of subsequent seizures.

The practical nurse (PN) at an extended care facility is called to the unit's activity room where a client has "fainted". Which finding indicates to the PN that the client experienced a syncopal episode? A sudden experience that everything went black. Incontinence of urine and stool. Blood pressure of 140/98. Severe headache with nausea and sensitivity to light.

A sudden experience that everything went black. In syncope or "fainting", the client experiences a sudden loss of consciousness (A). Incontinence of urine or stool (B) is typical for a seizure disorder, not syncope. A sudden fall in blood pressure (C) is common with syncope, which may rebound as the client gains consciousness. (D) is typical of migraine headaches, not syncope.

What is the immediate assessment the practical nurse (PN) should implement for a client who returns to the unit after a cardiac catheterization? Evaluate color of toes. Assess apical pulse. Determine the IV infusion rate. Check the client's groin.

Check the client's groin. Cardiac catheterization is most commonly accessed using the femoral artery, so it is essential to check the groin puncture site (D) and pressure dressing for signs of hemorrhage or hematoma formation. Although (A, B and C) should be implemented during the postprocedure period, the risk for bleeding from the arterial puncture site is the first assessment.

The practical nurse (PN) receives report on a group of clients assigned for the day. Which priority assessment should the PN implement? Check the pulse oximeter for a client with myasthenia gravis. Assess a client with multiple sclerosis for bowel incontinence. Determine the presence of nuchal rigidity in a client with resolving meningitis. Perform Glasgow Coma Scale (GCS) assessment for a client with a concussion.

Check the pulse oximeter for a client with myasthenia gravis. Myasthenia gravis results in weakness of the upper body muscles, including the muscles involved in swallowing and respirations, so assessing the client for adequate oxygenation is essential (A). Bowel and bladder incontinence are anticipated symptoms of multiple sclerosis and are not urgent assessments (B). (C) and (D) are important assessments but checking the oxygenation level of a patient with the possibility of respiratory compromise is most important.

The practical nurse (PN) is caring for a male client who is dying and assigns components of the client's care to the UAP. Which intervention should the PN implement? Sit with the client who is withdrawn, crying, or upset. Obtain client vital signs and complaints of discomfort. Determine client's priority needs for supportive care. Listen to family's feeling about the client's life choices.

Determine client's priority needs for supportive care. The PN should determine the priority supportive needs (C) to provide based on the client's plan of care. (A, B, and D) are examples of assistive, supportive measures that a UAP can provide to a dying client and his family.

The practical nurse (PN) is reviewing prescriptions for four clients. Which prescription should the PN question? Restrain in geri-chair for confusion and wandering. Monitor continuous passive motion machine's angle of flexion. Encourage incentive spirometer PRN for wheezing. Apply BiPAP machine during the hours of sleep.

Encourage incentive spirometer PRN for wheezing. Incentive spirometer (C) should be questioned because its use increases inspiratory reserve and prevents atelectasis but is not effective for wheezing, which is most commonly associated with asthma. (A) provides a prescription to ensure the client's safety. The use of continuous passive motion (CPM) (B) is prescribed at incremental angle flexion to ensure joint mobility after surgery. (D) gives constant airway pressure to keep airways opened for a client with sleep apnea.

A client is found pulseless and unresponsive with the telemetry showing a rapid, wide QRS complex. What should the practical nurse do first? Use an automated external defibrillator (AED). Initiate cardiac compressions. Ventilate with an Ambu bag. Suction the client and open the client's airway.

Initiate cardiac compressions. Ventricular tachycardia is life-threatening because it does not produce adequate cardiac output and perfusion and will progress to ventricular fibrillation. Basic life support should be initiated because the client is pulseless and unresponsive, so cardiac compressions are given first (B) at 100 times/minute. Once assistance arrives, (A, C, and D) can be given.

The practical nurse (PN) is caring for a client who had a lumbar laminectomy 4 hours ago. Which finding should the PN report to the healthcare provider? Hypoactive bowel sounds. Leg muscle strength grade 2. Emesis of green fluid. Urinary output of 50 ml/hour.

Leg muscle strength grade 2. Evaluation of spinal motor nerve innervation of skeletal muscles is based on muscle strength response. A decrease in muscle strength (B) (normal muscle strength is grade 5) indicates spinal nerve impairment, a possible complication of spinal surgery, and should be reported to the healthcare provider. (A, C, and D) are findings within normal limits for a client in the immediate postoperative period.

The practical nurse (PN) is monitoring a client with a comminuted fracture of the left femur. Which finding should the PN report to the healthcare provider immediately? Rising creatine phosphokinase (CPK). Elevated white blood count (WBC). Leg pain of "10" unrelieved by opioids. Weak left pedal pulses palpated.

Leg pain of "10" unrelieved by opioids. Compartment syndrome, an emergency complication of circulatory impairment, is manifested by severe pain unaffected by opioid analgesics (C), which should be reported immediately. (A and B) are common findings consistent with trauma. Although (D) should be reported, the presence of a pulse point provides some oxygenation to distal tissues.

A client who is 2-days postoperative for abdominal surgery has a nasogastric tube (NGT) to low continuous suction. The client tells the practical nurse (PN) that his mouth is so dry, he has been drinking water to quench his thirst. Which potential imbalance should the PN monitor for development in the client? Fluid volume excess. Metabolic alkalosis. Hyperkalemia. Hypercalcemia.

Metabolic alkalosis. Correct The continuous gastric suction and the fluids the client drank increases the washing out gastric hydrochloric acid, which places the client at risk for metabolic alkalosis (B). (A, C, and D) are unlikely with gastric suction.

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. The client is hypotensive, so the first action is to place the client's head of the bed flat (C) to increase cerebral circulation. Based on the client's vital signs, (A) should be evaluated next. Although deep breaths (B) increase lung expansion, the client's respiratory rate indicates the client needs oxygen which should be determined by measuring the client's SpO2 (D).

A client who is one-day post-thyroidectomy begins to develop a stridor. Which priority action should the practical nurse implement? Prepare for emergency tracheotomy at the bedside. Insert a large bore needle for IV access. Give the client oxygen per face mask. Assess the client for signs of hypocalcemia.

Prepare for emergency tracheotomy at the bedside. A complication after thyroidectomy is laryngeal edema, which is manifested by a stridor, so the client should be prepared for imminent emergency tracheotomy (A). Although (B, C, and D) may be implemented, the priority is alleviation of the client's upper airway obstruction per emergency tracheotomy.

A client who received several units of blood for a hemorrhagic event is reporting muscle cramps and a tingling sensation. Which action should the practical nurse implement? Administer a PRN analgesic. Instruct client to breathe into a paper bag. Obtain blood specimens for hemoglobin and hematocrit levels. Review laboratory results for serum calcium and magnesium levels.

Review laboratory results for serum calcium and magnesium levels. Multiple transfusions can affect electrolyte balance because calcium-binding products are added to the units of blood to prevent coagulation. Serum calcium and magnesium levels (D) should be monitor to detect hypo-concentration of the electrolytes that contribute to neuromuscular irritability. The client's discomfort should be managed by correcting the electrolyte imbalance (A) before the onset of tetany. (B) is ineffective for these symptoms caused by hypocalcemia. (C) evaluates the client's response to the transfusion and are not specifically related to the client's onset of cramping and paresthesia after multiple transfusions.

The practical nurse (PN) determines that a female client who is returning to the clinic with urinary urgency, frequency, and burning on urination has been in the clinic several times in the past few months with urinary tract infections (UTIs). The client asks the PN how to prevent these infections from reoccurring. What information should the PN give to this client? (Choose all that apply.) Take all of the prescribed antibiotic. Void before and after sexual intercourse. Do not drink carbonated drinks. Use vaginal douches and sprays. Wipe from front to back after voiding.

Take all of the prescribed antibiotic.\ Wipe from front to back after voiding. Void before and after sexual intercourse. (A, B, and E) are correct. Information that should help the client minimize recurrent UTI includes reinforcing the need to complete all of a prescribed antibiotic (A) even if symptoms resolve after 1 to 2 days of therapy. Hygienic practices, such as emptying the bladder before and after sexual intercourse (B) and wiping from front to back after urinating (E) reduce bacteria introduction into the urethra. Drinking plenty of fluids is often recommended, and avoiding (C) does not necessarily reduce the risk for UTIs. Vaginal douches, harsh soaps, bubble baths, powders, and sprays in the perineal area (D) can irritate the meatus and facilitate bacterial entrance and should be avoided.

Peripheral vision can be estimated using what test?

the confrontation test

A client who accidentally received an electrical shock at work and temporarily lost consciousness is brought to the emergent care center by his supervisor because the client states that he doesn't feel well. What intervention should the practical nurse implement first? Administer supplemental oxygen. Attach a cardiac monitor. Determine the level of pain. Check for any wounds.

Attach a cardiac monitor. The major cause of death from electrical injuries is cardiac dysrhythmia. The client's syncopal episode after the electrical shock indicates a possible cardiac complication, so electrodes for cardiac monitoring (B) should be applied first. (A) is not a priority need for a client after an electrical injury. (C and D) can be addressed after evaluating the client for insult to cardiac function.

A male client calls the clinic and reports he is having heavy chest pressure after exercising. He tells the practical nurse (PN) that he took three nitroglycerin sublingual (SL) tablets without relief. What instruction should the PN provide? Call 911 immediately. Go to the emergency department. Take another SL tablet of nitroglycerin. Chew a tablet of aspirin 325 mg.

Call 911 immediately. If three nitroglycerin SL tablets are ineffective, the client should call 911 immediately (A) to activate the emergency medical system (EMS) (A). (B) places the client at risk for a potentially life threatening event without immediate medical assistance. (C) may be indicated if the client has developed a tolerance to nitroglycerin. (D) should be implemented once EMS is in place.

The practical nurse (PN) is assisting with the admission of a client with postnecrotic cirrhosis. Which finding is most important for the PN to report to the charge nurse? Prolonged prothrombin time (PT). Jaundiced sclera. Confusion times one (person). Elevated aspartate aminotransferase (AST).

Confusion times one (person). Correct Hepatic encephalopathy is a manifestation of end-stage liver disease caused by the accumulation of ammonia, which is manifested by neurological changes. To ensure client safety, changes in the levels of orientation (person, place, and time) (C) require treatment and should be reported. (A, B, and D) are expected findings of cirrhosis.

A client who had an abdominal cholecystectomy today has a T-tube that has drained 200 ml of greenish-brown fluid in the past 12 hours. What action should the practical nurse (PN) take? Irrigate the T-tube with 100 ml of warm normal saline. Document the findings in the electronic medical record. Clamp the T-tube and notify the healthcare provider. Assess the client's vital signs for early signs of shock.

Document the findings in the electronic medical record. This is an expected amount and color of biliary drainage from a T-tube, which may drain between 250 to 500 ml during the first 24 hours (B) after a cholecystectomy. The T-tube should not be irrigated (A) nor clamped (C). There is no indication that the client is in shock (D).

The practical nurse (PN) obtains an oral temperature of 100°F (37.8°C) for a female client who is one day postoperatively after a total abdominal hysterectomy. What action should the PN implement? Evaluate the client's temperature in 4 hours. Encourage incentive spirometer use every 2 hours. Inspect abdominal dressing for purulent drainage. Administer a prescribed analgesic-antipyretic.

Evaluate the client's temperature in 4 hours. An oral temperature of 100°F (37.8°C) on the first postoperative day is not indicative of infection and should be monitored every 4 hours (A). (B, C, and D) are implemented for postoperative prevention of infections, which are more likely to manifest in 48 to 72 hours postoperatively.

The practical nurse (PN) is caring for client who returned to the unit after a cardiac catheterization. Which finding should the PN report to the nurse? Bilateral tinnitus. Faint pedal pulses. Pitting edema. Circumoral numbness.

Faint pedal pulses. Decreased pedal pulse volume (B) after a cardiac catheterization may indicate of arterial occlusion of the femoral artery used during the procedure and should be reported to the charge nurse. Although (A, C, and D) may be related to the client's underlying cardiac status, these findings are not a complication of cardiac catheterization.

Which technique should the practical nurse implement for a male client who does not response to nail bed pressure during a focused neurological assessment? Provide painful stimuli using a sternal rub technique. Shake the client's shoulder to illicit responsiveness. Use environmental stimuli by turning lights off and on. Ask the client to repeat his name and date of birth.

Provide painful stimuli using a sternal rub technique. A client who is unresponsive to verbal, tactile, or one form of painful stimuli should be assessed using maximum stimulation for maximum response, such as a sternal rub (A) which is another type of painful stimulation. (B and C) are forms of tactile or sensory stimuli. The client must be conscious to respond to verbal stimuli, such as levels of orientation (D).

A male client with increased intracranial pressure (ICP) due to a skull fracture is in the supine position with his legs elevated. What should the practical nurse (PN) do first? Obtain the client's vital signs. Raise the head 30 degrees and lower the feet. Complete a Glasgow Coma Scale. Check the IV infusion rate and urinary output.

Raise the head 30 degrees and lower the feet. Elevating the legs above the head increases venous pressure which increases ICP. The first action is to lower the client's feet and raise his head 30 degrees to minimize brain swelling and cerebral anoxia. (A, C, and D) can be implemented after (B).

The nurse is caring for a patient who has been abusing a CNS depressant. Which of the following signs and symptoms might be seen in this patient? Select all that apply.

Decreased respirations Memory loss Slurred speech

A client with a peptic ulcer develops severe upper abdominal pain. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Deep, rapid respirations. Rigid, board-like abdomen. Vomiting of undigested food. Hyperactive bowel sounds.

Rigid, board-like abdomen. A rigid, board-like abdomen indicates perforation of a bleeding peptic ulcer (B) and possible peritonitis. (A, C, and D) should be reported, but a rigid, board-like abdomen is a surgical emergency.

On admission, a client with an acute myocardial infarction receives a thrombolytic, aspirin, and IV heparin. Which finding indicates to the practical nurse (PN) that the client is having a therapeutic response to the medication? Lungs clear bilaterally and heart tones regular in rate and rhythm. Ankle edema decreased from 3+ to 1+. Activated partial thromboplastin time (APTT) results 2 times the control. Platelet count greater than 150,000/mm3.

Activated partial thromboplastin time (APTT) results 2 times the control. Acute Coronary Syndrome (ACS) protocol includes the administration of thrombolytics, aspirin, and IV heparin, which prolongs the activated partial thromboplastin time at the therapeutic range that is two times the control value (C). This protocol of medications has no therapeutic effect on lungs sounds (A), heart rate or peripheral edema (B), or platelet count (normal platelet count is 100,000 to 400,000/mm3) (D).

The practical nurse (PN) is caring for a client with a chest tube connected to a closed chest drainage system to suction at 20 cm of water pressure. The sterile water in the suction chamber is gently bubbling at the water level of 15 cm. What action should the PN take? Increase the wall vacuum to cause vigorous bubbling in the suction chamber. Add sterile water to the suction control chamber to the 20 cm mark. Assess for an air leak after clamping the chest tube with a small hemostat. Encourage the client to breathe deeply and slowly every 2 hours.

Add sterile water to the suction control chamber to the 20 cm mark. The amount of suction applied to the chest wall is regulated by the amount of water in the suction control chamber, not by the amount of vacuum applied to the system. The gentle bubbling in the suction chamber causes water to evaporate and must be added periodically to the chamber (B) to the prescribed level of 20 cm. Turning the vacuum source higher (A) causes the bubbling to become vigorous and makes the water evaporate faster, but does not increase the amount of suction. An air leak is considered when there is continuous bubbling in the water-seal chamber, which is evaluated by clamping the chest tube momentarily for assessment (C). The client is encouraged to breathe deeply (D) to facilitate the lung expansion, but it does not affect the amount of negative pressure.

A client presents to the clinic complaining of severe stabbing pain in the epigastric region that radiates to the mid-back area. Which finding indicates to the practical nurse that the client should remain NPO? Amylase and lipase levels are 3 times the normal value. Alanine aminotransferase (ALT) is 4 times the normal value. White blood count is 14,000 mm3. Serum potassium is 3.2 mEq/L.

Amylase and lipase levels are 3 times the normal value Pancreatitis is confirmed by amylase and lipase levels that are elevated 2 to 3 times the normal value (A). Clients with pancreatitis should be kept NPO, which allows the pancreas to rest. An elevation in ALT levels (B) is characteristic of liver disease. WBC elevation (C) indicates infection. A low serum potassium level (norm is 3.5 to 5.5 mEq/L) indicates hypokalemia. Although (B, C, and D) require further assessment by the healthcare provider, they do not require an NPO status.

An adult male who is covered with "road rash" after falling off his bicycle arrives at the clinic. He holds his hand to his chest and tells the practical nurse (PN) that he hurts when he breathes. The PN hears an audible "slurping" sound each time the client takes a breath. Which intervention should the PN implement first? Document findings and evaluate response to treatment. Request a prescription for an analgesic. Insert an IV saline lock and rinse superficial wounds. Apply oxygen and inspect the chest wall.

Apply oxygen and inspect the chest wall. Falls from a moving bicycle can cause a foreign body or fractured rib to penetrate the chest wall and create a "sucking" chest wound. The most important action is to apply oxygen (D) and inspect the chest wall surface for a wound that may require immediate action. (A) should be implemented once the client's care is provided or delegated to another caregiver. (B and C) should be obtained after providing supplemental oxygen.

A client who had abdominal surgery yesterday is receiving morphine via a patient-controlled analgesia (PCA) infusion pump. The client reports a pain level of 6 based on a pain scale of 1 to 10. What action should the practical nurse (PN) implement first? Take the client's blood pressure. Ask for a description of the pain. Remind client to push the PCA button. Check the intravenous tubing for kinks.

Ask for a description of the pain. The PN should obtain further information (B) about the pain the client is experiencing. (A, C and D) should be implemented after the client describes and locates the pain.

A male client is admitted with encephalitis and hourly neurological assessments are prescribed. At 0300, the client reports a headache rated at "8" on 0 to 10 pain scale. The practical nurse (PN) administers a prescribed PRN analgesic at 0315, and notes the client is asleep and snoring at 0400. What priority action should the PN take? Awake the client to check response to stimuli. Document the client's subjective pain level. Observe movement of all four extremities. Evaluate quality of bilateral pulse points.

Awake the client to check response to stimuli. Neurological assessments for a client with encephalitis include level of consciousness, complaint of headache, vital signs, response to stimuli, and strength and movement of all extremities. Observation of the client with encephalitis is necessary to detect subtle changes, so the client should be awakened every hour (A) as prescribed. Pain assessment should follow medication administration and be documented (B) to reflect the sequence of activities. Although (C and D) are parts of the neurological assessment, changes in level of consciousness and response to stimuli are the priority. Encephalitis is irritation and swelling (inflammation) of the brain, most often due to infections.

During admission to the medical unit, a client with bacterial meningitis complains that the light is hurting his eyes and he has a headache. The practical nurse (PN) reviews the client's pervious neurological responses and obtains the client's temperature, which is 103.1°F (39.5°C). Which action should the PN implement next? Administer a prescribed PRN antipyretic. Begin a secondary infusion of the prescribed antibiotic. Determine the time an analgesic was last administered. Perform a neurological assessment.

Begin a secondary infusion of the prescribed antibiotic. Immediate implementation of the treatment plan for prescribed antibiotics (B) should be initiated to prevent long-term neurological sequela. Once the infusion of antibiotics is started, antipyretics (A) and analgesia (C) should be administered. (D) should be done at regular and frequent intervals during treatment, but administration of the antibiotic is the next action.

A client with a vertebral fracture at T3 after falling from a roof is sent for radiological testing. Which assessment is a priority for the practical nurse (PN) to implement when the client returns to the unit? Bilateral hand grip and strength. Peripheral pedal pulses. Auscultation of all lung fields. Fingerstick glucose levels.

Bilateral hand grip and strength. Assessment for T3 neurological deficits due to spinal cord swelling should include evaluation of bilateral hand grip and strength (A). (B, C, and D) may be indicated, but the priority is a focus assessment for spinal cord injury related to the fractured vertebrae.

A 55-year-old male client with an abdominal aortic aneurysm (AAA) presents to the emergent care center reporting abdominal and scrotal pain and feeling dizzy. Which finding should the practical nurse report to the healthcare provider? Bladder distention. Cough with clear breath sounds. Hyperactive bowel sounds. Blood pressure of 160/90.

Blood pressure of 160/90. An AAA can manifests as a palpable abdominal mass that pulsates, which can cause pain in the abdomen, lower back, or scrotum as the aneurysm enlarges. To prevent rupture of the AAA, the client's must be maintained normotensive, so the elevated blood pressure (D) should be reported to the healthcare provider. (A, B, and C) are not related to AAA.

The practical nurse (PN) is performing a focused assessment for a postoperative client who returns to the unit after receiving general anesthesia. Which finding should the PN identify as an indicator that the client is free of respiratory complication? Client is able to use the incentive spirometer. Coughs effectively to produce yellow mucus. Respirations are 22 breaths/minute. Breath sounds are clear bilaterally.

Breath sounds are clear bilaterally. Clear lung sounds (D) indicate that the client is free of respiratory complication. (A) is indicative of the client's ability to use the equipment, not a physiological response. Expectorant mucus should be clear, not (B). (C) is not significantly abnormal, but may indicate the client is experiencing unrelieved pain.

A female client arrives at the clinic holding her abdomen and reports diffuse abdominal pain and a frothy greenish vaginal discharge. What intervention is most important for the practical nurse (PN) to implement? Ask about recent sexual activity. Collect vaginal discharge for culture. Obtain a blood specimen. Check urine with early pregnancy test

Check urine with early pregnancy test Based on the client's symptoms, it is most important to determine if the client has a possible ectopic pregnancy, so the PN should check the client's urine using an early pregnancy test (D). (A, B, and C) should be implemented after (D).

After receiving report, the practical nurse (PN) begins assessment for a client with chronic obstructive pulmonary disease (COPD) who has just completed a respiratory treatment. The PN finds the client sitting upright in bed with oxygen at 6 liters/minute per nasal cannula. Which intervention is most important for the PN to implement? Auscultate anterior and posterior lung sounds bilaterally. Institute measures to reduce oxygen consumption. Decrease oxygen flow rate to 2 liter/minute and attach pulse oximeter. Verify the oxygen flow rate with the healthcare provider's prescription.

Decrease oxygen flow rate to 2 liter/minute and attach pulse oximeter. The PN should question the flow rate at 6 liters/minute for a client with COPD, which can reduce the respiratory drive and cause respiratory arrest. The first action is to reduce the oxygen flow rate and determine the client's pulse oximetry reading. (A and B) can be implemented after reducing the oxygen flow rate. Although the oxygen flow rate should be verified with the healthcare provider's prescription (D), the client's respiratory drive has been reset by a chronic elevated CO2 level caused by COPD and high levels of supplemental oxygen should not be given.

A client with myasthenia gravis is admitted in myasthenic crisis. Which priority action should the practical nurse (PN) implement? Determine client's ability to swallow. Evaluate strength when walking to bathroom. Remind client to use the call light for assistance. Perform a fall risk assessment.

Determine client's ability to swallow. Myasthenia gravis affects the muscles involved in swallowing, respirations, and eyelid movement. The priority action is assessing the client's ability to swallow (A), which influences the client's risk for aspiration. (B, C, and (D) should be implemented, but do not have the priority of (A).

A male client with pancreatic cancer who received morphine and midazalom (Versed) during an endoscopic retrograde cholangiopancreatography (ERCP) returns to the unit. His vital signs are pulse 80 beats/minute, 16 breaths/minute, 120/80 blood pressure, and pulse oximeter 98%. Which action should the practical nurse (PN) implement? Give naloxone (Narcan) and flumazenil (Ramazicon) per protocol. Arouse the client to give warm oral fluids to sooth a sore throat. Determine client's fingerstick glucose level. Administer a 500 ml intravenous fluid bolus.

Determine client's fingerstick glucose level. A client with pancreatic involvement is likely to experience inadequate insulin secretion which places the client at risk for abnormal serum glucose, so the client fingerstick glucose level (C) should be checked. Based on the client's vital signs, (A and D) are not indicated at this time. The client's gag reflex is suppressed due to medication administered during the procedure, so fluids or food should be withheld (B) until the gag reflex returns.

The practical nurse (PN) is documenting the administration of a client's medication. Which entry by the PN complies with The Joint Commission (TJC) guidelines for use of abbreviations? MS 4.0 mg IM given for pain rated "8" on a scale of "0-10". IM 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. Recommendations from TJC about the use of abbreviations with medication administration include using a zero to precede the decimal point in dosage (C) and does not exclude using AC (before meals) or BID (twice a day). The "Do Not Use" list of abbreviations from TJC includes eliminating the use of initials for drugs, trailing zeros, and abbreviations u, SC, cc, and qd (A, B, and D).

A client recovering from a gastrojejunostomy (Billroth II) surgery reports dizziness, weakness, palpitations, and an urge to defecate about 20 minutes after eating. What teaching should the practical nurse reinforce with the client? Increase fluid intake during meals. Avoid lying down after meals. Limit gluten and purine intake. Eat low-carbohydrate foods 6 times/day.

Eat low-carbohydrate foods 6 times/day. The client is experiencing the signs and symptoms of dumping syndrome related to the malabsorption of carbohydrates due to a deficiency of digestive enzymes. The client should consume smaller, more frequent meals that are low in carbohydrates and refined sugar (D), moderate in fat, and moderate to high in protein. Fluids should be taken between meals, not (A). Lying down for about 30 minutes after meals is helpful, not (B). (C) is not indicated.

A female client who is currently receiving chemotherapy (CT) for colon cancer tells the practical nurse (PN) that she plans to become pregnant in case CT is not successful. What action should the PN take? Determine how the client's spouse feels about the decision. Assess the client's ability to perform activities of daily living. Reinforce the importance of proper nutrition during pregnancy. Encourage her to wait until the completion of chemotherapy.

Encourage her to wait until the completion of chemotherapy. CT is teratogenic and causes birth defects in the first trimester, so the client should be encouraged to wait until CT is completed (D) and talk with her healthcare providers about the treatment risks in pregnancy. (A, B, and C) do not address the risk of CT in pregnancy.

Which intervention should the practical nurse (PN) implement for a client who is scheduled for a lumbar puncture? Explain the reason for the procedure. Check results of coagulation studies. Ensure the client's bed is positioned flat. Schedule the special procedures room.

Ensure the client's bed is positioned flat. The PN should ensure the client's bed is flat (C) to facilitate the healthcare provider's access in the subarachnoid space during the procedure and minimize the risk for a "spinal headache" from the loss of the cerebral fluid after the procedure. Explanation of reasons (A) including the risks and benefits of the procedure should be provided by the healthcare provider. The risk for bleeding is minimal during a lumbar puncture (LP), so coagulation studies (B) are not routinely obtained. Although (D) is an option, LP can be performed at the client's bedside.

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? Allow the client to do hygienic care first at the bedside. Let the client sponge in the bathroom with assistance. Permit the client to shower with assistance as requested. Explain the need for starting the transfusion immediately.

Explain the need for starting the transfusion immediately. The client's hemoglobin indicates active bleeding, and the PN should explain the need for immediate transfusion administration (D) to prevent shock. Once the transfusion is in progress, the client may be offered hygiene (A and B) as tolerated. (C) is not indicated.

A client with type 2 diabetes mellius (DM) presents in the clinic with a leg laceration that has not healed in two weeks. Which client data is most important for the practical nurse to collect? Serum electrolyte results. Use of vitamin C supplements. Daily administration of insulin. Fingerstick glucose level.

Fingerstick glucose level. Poor wound healing is often a sign of uncontrolled diabetes mellitus, so a fingerstick glucose level should be obtained first (D). Although (A) should be monitored during diabetic ketoacidosis, the priority is to determine the client's glucose level in response to poor wound healing and possible infection. Vitamin C (B) intake can influence wound healing, but managing the client glucose level is the priority. Type 2 DM is usually managed with oral antidiabetic agents, and (C) maybe indicated to promote healing based on the client's serum glucose.

A client with a history of epilepsy is admitted for back pain related to the presence of a cyst located at T6. The client has a tonic-clonic (grand mal) seizure and 30 minutes later is incontinent of urine. What is the priority action for the practical nurse to implement? Provide reassurance and privacy while providing incontinent care. Have the client push both feet against the nurse's hands. Determine the last dose administration of antiepileptic medication. Ask the client if an aura occurred prior to the seizure.

Have the client push both feet against the nurse's hands. Incontinence can occur during a seizure, but the delay of incontinence may be related to rupture of the spinal cyst which results in neurological impairment. Assessment of lower extremity function (B) is the priority. (A, C, and D) should be implemented, but the priority is focused assessment for possible complications.

The practical nurse (PN) recognizes which stool characteristics as typical of a client with acute cholecystitis? Pale, floating. Dark, tarry. Watery, odoriferous. Currant jelly, bloody.

In cholecystitis, bile, which emulsifies fat in the duodenum, is impeded by gallbladder irritation, ineffective ejection from the gallbladder, or gallstone obstruction of the common bile duct. Stool with increased fecal fat are characteristically are frothy and float, and clay-colored or pale (A) due to the lack of bile which contains biliruben that colors the stool. (B) is characteristic of gastrointestinal bleeding. Watery diarrhea with a horse barn odor is classic of Clostridium difficile infection (C). Bloody, currant jelly stool typically occur with intussusception (D).

A number of clients have arrived for care in a crowded emergent care center. Which assignment should the practical nurse (PN) accept? Flush a client's eyes who was exposed to a facial chemical splash. Obtain the history of an adult who attempted suicide. Accept an incoming trauma victim of a vehicle collision. Insert nasogastric tube for an older adult with abdominal distention.

Insert nasogastric tube for an older adult with abdominal distention. Insertion of a nasogastric tube (D) is within the scope of the PN. Clients who have experienced caustic eye trauma (A), a suicide attempt (B), and admission of a trauma victim (C) require the knowledge and skill of an experienced nurse.

A client with type II diabetes mellitus (DM) is admitted with an infected foot ulcer. Which prescription should the practical nurse (PN) implement first? Intravenous antibiotics. Diabetic foot care teaching. Metformin (Glucophage). Daily foot dressing changes.

Intravenous antibiotics

A male client is admitted to the medical unit after falling off a second story roof to a concrete sidewalk. The client's skin is warm and pink, and his vital signs are heart rate 60 beats/minute, respirations 26 breaths/minute, blood pressure 80/48. Which action is most important for the practical nurse to implement? Neurological assessments every 2 hours. Maintain normal saline infusion and IV access. Monitor the pulse oximeter and temperature. Administer prescribed mannitol (Osmitrol) IV.

Maintain normal saline infusion and IV access. The client who is experiencing spinal shock after falling from a building should receive IV normal saline to maintain perfusion (B). (A and C) are ongoing assessments that are implemented after emergency interventions are initiated. Mannitol is not indicated at this time (D).

The practical nurse (PN) receives shift report about a client whose chest x-ray reveals "free air under the right diaphragm." What action should the PN take? Maintain the client NPO. Position the client on the left side. Encourage ambulation to expel flatus. Administer a PRN antacid.

Maintain the client NPO Free air under the diaphragm on an upright chest x-ray is most often indicative of a gastrointestinal perforation, and the client will probably need surgery, so the client should be kept NPO (A) until that determination is made. Since the air is outside the colon, hence the term free air, it will not help to position (B) or ambulate (C) the client. (D) is not indicated.

A client presents to the emergent care center with symptoms on an acute brain attack and right sided facial drooping. Which action should the practical nurse (PN) implement first? Maintain the client NPO. Insert a nasogastric tube. Determine if the client has a gag reflex. Prepare client for computerized tomography.

Maintain the client NPO. An acute brain attack, or cerebrovascular accident (CVA), is commonly manifested with facial drooping and dysphagia, so the client should be maintained NPO (A) to minimize the risk of aspiration. Although (B, C, and D) should be implemented, first the client should not have anything by mouth.

An older client who is at a health fair goes to the First Aid station and reports feeling tired after a recent screening test revealed a hemoglobin of 10.1 grams. The client asks the practical nurse (PN) what could he do to feel better. What information should the PN offer? Eat food high in iron, for example red meat. Take an over-the-counter iron supplement. Practice daily stress-relieving measures. Make appointment with healthcare provider.

Make appointment with healthcare provider. A common cause of anemia in the elderly is blood loss from the gastrointestinal or genitourinary tracts, so the PN should recommend that the client visit to the healthcare provider for further assessment (D). The cause of the anemia must first be determined before attempting to treat it as iron-deficiency anemia through diet (A) or supplements (B). Stress-relieving measures (C) are always a healthful option, but the etiology and proper treatment of the known problem is a priority.

A client who is hit on the head with a baseball bat is admitted for observation. The practical nurse (PN) notes clear liquid leaking from the client's ear. What action should the PN take? Pack the ear loosely with a dry, sterile dressing. Observe the collected fluid for blood surrounded by a yellow ring. Obtain a sample of the liquid for an anaerobic culture. Test the liquid's pH at the bedside using a test strip.

Observe the collected fluid for blood surrounded by a yellow ring. Correct Basal skull fractures that tear the dura are associated with leakage of cerebrospinal fluid (CSF) from the ear or the nose. The presence of the "halo" sign (fluid leakage that includes blood coalesces in the center and outlined by a yellow ring) is consistent with CSF leakage (B). (A, C, and D) are not indicated.

A client who is experiencing an acute asthma attack is receiving rescue medication. The practical nurse (PN) reviews the client's history to determine the client's respiratory function over the past few months. Which device results should the practical nurse review to obtain data that measures the client's personal best respiratory function? Pulse oximeter. Chest x-ray. Incentive spirometer. Peak flow meter.

Peak flow meter A peak flow meter (D) measures the client's ability to breathe air out and provides information regarding the client's personal best respiratory status. (A, B, and C) do not indicate air flow volumes that indicate the client's respiratory function. (A) measures current oxygenation. (B) shows lung fields. (C) is used to help clients expand their lungs to prevent atelectasis.

During the daily assessment of a client with emphysema, the practical nurse (PN) identifies that the client's chest is barrel-shaped and he is demonstrating pursed-lip breathing. Which additional finding requires follow up by the PN? Pulse oximetry is 90% on room air. White blood cell (WBC) count is 9,900 mm3. Dyspnea when ambulating in the hall. Rales auscultated bilaterally.

Rales auscultated bilaterally. Barrel chest and pursed-lip breathing are classic signs of chronic obstructive pulmonary diseases (COPD), such as emphysema. The presence of bilateral rales (D) indicates that is client has pulmonary congestion or an infection which can easily overwhelm a client with the disease and requires follow up. (A and C) are common findings for a client with COPD. (B) is within normal limits (norm WBC is 5,000-10,000 mm3).

The practical nurse (PN) is caring for a client who has increased intracranial pressure (ICP) and a nursing diagnosis of Ineffective breathing pattern. Which intervention should the PN use as the best measure for attainment of the goal, "Client will have adequate oxygenation?" Measure respiratory rate and depth every 2 hours. Perform hourly neurological assessment checks. Maintain the head of bed elevated at 30 degrees. Review current results of arterial blood gas studies.

Review current results of arterial blood gas studies. Adequate client oxygenation is best evaluated by examining blood gas values (D). (A and B) provide indirect evidence of effective oxygenation. (C) may reduce ICP and improve cerebral oxygenation but does not provide evaluative data.

A client who is 12 hours postoperative for a right total knee replacement (TKR) is receiving epidural pain management. Which finding requires additional follow-up by the practical nurse (PN)? Reports knee pain as a "6" on a 10 point scale. Nonproductive cough after incentive spirometer use. Feet are cool to touch and covered with 2 blankets. Right dorsal pedal pulse absent upon palpation.

Right dorsal pedal pulse absent upon palpation. Absent pedal pulses in the operative leg is indicative of arterial occlusion, a postoperative complication of TKR, and requires further assessment (D). (A, B, and C) are expected findings following knee replacement surgery.

Which finding should the practical nurse (PN) report to the healthcare provider that indicates a client with cirrhosis is progressing to hepatic encephalopathy (hepatic coma)? 2+ pitting edema up to the lower thighs. Serum clotting results three times above normal. Spider nevi (telangiectasias). Serum ammonia levels twice the normal value.

Serum ammonia levels twice the normal value. Hepatic coma results in cerebral dysfunction when serum ammonia is not eliminated and builds up in the bloodstream (D). (A, B, and C) are all expected findings for clients with cirrhosis, but elevated serum ammonia level is indicative of hepatic failure.

A client is 24 hours post-endoscopic retrograde cholangiopancreatography (ERCP) for cholelithiasis. Which finding should the practical nurse (PN) report to the healthcare provider? Serum bilirubin elevation four times above normal value. Serum amylase elevation 3 times above normal value. Steatorrhea. Jaundiced sclera.

Serum amylase elevation 3 times above normal value. ERCP can cause a gallstone to move into the common bile duct, obstructing flow into the duodenum and cause pancreatitis, which is evidenced by an elevation of serum amylase (B) and lipase levels. Elevated bilirubin (A), steatorrhea (C), and jaundice (D) are expected findings with cholelithiasis

A male client who arrives at the clinic for an eye examination tells the practical nurse (PN) that he has recently experienced blurred vision. Which finding is most important for the PN to report to the healthcare provider? Inability to identify the colors of numbers on an eye chart. Left pupil consensual response to pen light exposure in right eye. Small rapid, rhythmic, oscillating movements of eyeballs. Pupils constrict when focusing on a distant object that moves to the face.

Small rapid, rhythmic, oscillating movements of eyeballs. Nystagmus, an abnormal, involuntary and rapid twitching or oscillation of the eyeball (C), requires further assessment and should be reported to the healthcare provider. (A) most likely indicates color blindness, which requires no further action. A consensual response to light stimulus (B) and pupillary responses during accommodation for near vision (D) are normal findings.

A female client who is postmenopausal calls the clinic and states that she has been spotting for the last three days. What action should the practical nurse (PN) implement? Suggest that she uses lubricant during intercourse. Tell the client to come to the clinic today. Determine if she is taking hormone replacement. Ask client if she has pain during urination.

Tell the client to come to the clinic today. Postmenopausal bleeding is an abnormal finding which can be a sign of endometrial cancer, so the PN should tell the client to come to the clinic today (B). (A, C, and D) are not indicated at this time.

With the onset of a patient with Unilateral facial drooping what assessment does the nurse do to distinguish between bell's palsy and stroke?

Test all 4 extremities for strength and movement. Unilateral motor deficits are the most obvious effects of a stroke and not bell's palsy.

A male client who is unconscious after blunt trauma to the head during a baseball game is admitted for observation for possible epidural hematoma. The client is awake and oriented at each hourly check and becomes more difficult to arouse. Which additional finding should the practical nurse report? Hyperactive gag reflex. Nuchal rigidity. Vomiting. Bounding peripheral pulses.

Vomiting A client with an epidural hematoma, an arterial intracranial bleed, typically manifests unconsciousness at the scene of the injury followed with lucid intervals of orientation, decreasing levels of consciousness, and other symptoms, such as vomiting (C) or focal findings, which should be reported. (A, B, and D) are not indicative of increasing intracranial pressure.

The nurse has provided discharge instructions regarding nitroglycerin therapy to the client with angina. Which statement by the client indicates an understanding of the home use of nitroglycerin? a) "if i use the nitroglycerin and the pain does not subside in 15 minutes, I should go to the hospital." b) "When I have pain, I should lie down and place a tablet under my tongue. If unrelieved in 5 minutes, I should call for an ambulance." c) When I have chest pain, I should put a tablet under my tongue. If I have a burning sensation, I should call my doctor immediately." d) "When I experience chest pain, I can continue what I'm doing. If it doesn't go away in 10 minutes, I should use a nitroglycerin tablet."

b

The practical nurse (PN) performs a Glasgow Coma Scale (GCS) assessment for a client who experienced an acute brain attack (stroke) yesterday and obtains a score of "12". What assessment should the PN do next? Verbal responses and speech patterns. Extremity movements in response to commands. Ability to open eyes to stimuli. Comparison of GCS score with previous checks.

Comparison of GCS score with previous checks. A key element in neurological assessments is the client's trends, which can be subtle changes, so the PN should compare the client's present score to previous scores to determine if the client is better, worse, or the same (D). (A, B, and C) are components of the GCS.

A male client who fell from a fire escape staircase has no sensation or movement of his lower extremities. His vital signs are heart rate 54 beats/minute, respirations 20 breaths/minute, blood pressure 86/50, and pulse oximetry 95%. He is admitted with an normal saline IV infusion to maintain perfusion, and his skin is cool, dry, and pink. Which action is most important for the practical nurse to implement? Complete q2 hour neurological assessments. Continue supplemental oxygen per nasal cannula. Monitor hourly urinary output per indwelling catheter. Minimize environment stimuli by dimming lights.

Monitor hourly urinary output per indwelling catheter. Neurogenic shock after spinal injury presents as bradycardia and hypotension due to the loss of peripheral vasoconstriction below the level of injury. The skin is dry to the touch because of an inability to sweat and skin temperature takes on the same temperature as the room. The priority is the monitor hourly urinary output (C), which evaluates adequate perfusion. (A, B, and D) do not have the priority of monitoring perfusion and urinary output.

The practical nurse (PN) is reviewing the admission data for an older male with benign prostatic hyperplasia (BPH). Which finding should the PN report to the healthcare provider? Night time awakenings 5 times to void. Urinary stream is weak and dribbles. Blood urea nitrogen (BUN) is 50 mg/dl. Urinalysis results reveals 1+ mucus.

Blood urea nitrogen (BUN) is 50 mg/dl. If left untreated, BPH can cause lower urinary tract symptoms (LUTS), urinary tract infection (UTI), hematuria, or compromised upper urinary tract function, which is reflected by an elevated BUN level (C) (norm 10 to 20 mg/dl) that indicates the kidney is unable to clear nitrogenous wastes from the blood. Frequent nocturnal voiding (A) and a weak urinary stream (B) are common symptoms of BPH, which impact a client's quality of life, but these findings are not as important as an elevated BUN. (D) is not significant and may indicate a contaminated specimen.

An adult client presents to the emergent care center with hives and laryngeal edema after being stung by a bee. Following successful treatment, what information is most important for the practical nurse to reinforce with the client upon discharge? Avoid bees. Keep oral benadryl accessible. Carry an epinephrine pen. Obtain medical alert bracelet.

Carry an epinephrine pen. A client who experiences a severe, life-threatening allergic reaction to a bee sting is at risk for anaphylaxsis 12 hours after the initial symptoms subside, a biphasic reaction that occurs in about 20% of these reactions. The client should carry an epinephrine auto-injector, such as an EpiPen (C), for emergency treatment of anaphalytic shock. The client should avoid bees (A), but an EpiPen should be available for immediate use if exposed again. Although oral benadryl (B) is used to treat allergic reactions, its onset is ineffective in responding to anaphylaxis. Wearing a medical alert bracelet (D) is advisable, but it is not as important as carrying an EpiPen.

An older female client with heart failure (HF) calls the clinic and tells the practical nurse (PN) that she has been coughing after starting the prescription, captopril (Capoten). Which information by the client requires further investigation by the PN? Feels tired after a shopping trip. Complains her shoes are too snug to wear. Sees floaters in her visual fields at times. Takes an over-the-counter cough syrup.

Complains her shoes are too snug to wear. The weakened pumping action of the heart causes excess fluid retention that causes weight gain and edema, which is evidenced by shoes (B) or clothes that become too tight to wear. Fatigue (A) is a common symptom of HF. Seeing floating spots in front of the eye (C) are often vitreous humor debris that occurs with aging. (D) may be used for coughing, a side effect of ACE inhibitors, but increasing fluid retention is indicative of an exacerbation of HF.

The practical nurse (PN) is discussing cancer screening for a group of women who attend a healthy living seminar at the clinic. What information should the PN review? Adult females should have a colonoscopy once they reach age 65. A screening mammogram should be performed starting at age 21. An endometrial biopsy is indicated for irregular menstrual bleeding. The Pap smear test is recommended when sexual activity begins.

The Pap smear test is recommended when sexual activity begins. The human papilloma virus (HPV) is a sexually transmitted infection that causes slow-growing cervical cancer. The Pap smear identifies early cervical cell changes and should be recommended when sexual intercourse begins (D). Adults should have a screening colonoscopy at age 50, not (A). Baseline mammograms (B) are recommended usually at age 40. (C) is recommended for vaginal bleeding in postmenopausal women, not as a screening test for other menstrual irregularities.

The practical nurse (PN) is irrigating the eye of a male client who had a known alkaline substance splashed into his eye. Which finding indicates the PN should stop the procedure? The client no longer experiences any eye pain. The client's Snellen test is 20/40. The pH is 7.4 in the affected eye. Red reflection is seen using ophthalmoscope.

The pH is 7.4 in the affected eye. Alkali injuries in the eye can penetrate conjunctival tissues more readily than acids, so irrigation with copious amounts of water should continue until the pH of the eye returns to normal (C). Absence of eye pain (A) is not a reliable indicator that treatment should be stopped. Visual acuity should be measured, but it is not a reliable indicator that all of the alkaline substance has been removed (B). A red reflection is usually related to a corneal abrasion (D).

The practical nurse (PN) is transferring a client to the in-patient dialysis unit for hemodialysis scheduled for today. Which information is essential for the PN to report to the receiving nurse? Last 24-hour intake records. Potassium dietary restrictions. Schedule of antihypertensive prescriptions. Today's hemoglobin result of 8.0 grams.

Today's hemoglobin result of 8.0 grams. The PN should report the client's recent hemoglobin level (D), which is low and is essential information in planning the client's care for hemodialysis. (A and B) are standards of care for a client who is receiving dialysis. Although routine antihypertensive drugs (C) are withheld before hemodialysis, the priority is the client's need for possible blood transfusion during the next hemodialysis session.

A client presents to the urgent care clinic with a sudden onset of left upper quadrant pain radiating to the back. Based on which laboratory values should the practical nurse (PN) ensure the client remains NPO? (Select all that apply.) Glucose is 150 mg/dL. White blood cell count of 11,000 mm3/L. Alanine Aminotransferase (ALT) is 144 units/L. Amylase is 660 units/L. Lipase is 1600 units/L. Aspartate Aminotransferase (AST) is 140 units/L.

Amylase is 660 units/L. Lipase is 1600 units/L. Elevation of amylase (D) and lipase (E) indicates the probability of pancreatitis, and the client should be NPO to prevent stimulation of pancreatic activity. Although (A and B) are elevated, they do not require the client to be NPO. (C and F) are elevated and indicative of possible liver disease, but the client does not need to be NPO.

A 60-year-old client with benign prostatic hyperplasia (BPH) has been up to the bathroom six times during the night. The client asked the practical nurse (PN) if there is something the healthcare provider can do to help him with this problem before he has a transurethral resection of the prostate (TURP). What information should the PN offer? A prescribed diuretic can be taken in the morning to reduce night-time voiding. There are no other treatments unless there is evidence of cancer. Practicing pelvic floor exercises can reduce dribbling of urine. An indwelling catheter is sometimes prescribed to alleviate symptoms.

An indwelling catheter is sometimes prescribed to alleviate symptom. To provide comfort and prevent urinary and kidney damage preoperatively, the insertion of an indwelling urinary catheter (D) can be prescribed to relieve urinary retention caused by the enlarged prostate that is encroaching on the urethra. (A, B, and C) are inaccurate information for the client's condition.

When assisting the nurse in the collection of a specimen for arterial blood gases (ABG), which action should the practical nurse (PN) implement? Compress radial and ulnar arteries and release to evaluate skin color. Apply the tourniquet approximately 6 inches above the puncture site. Provide pressure to puncture site for 30 seconds after specimen collection. Store the ABG specimen in a sterile biohazard bag at room temperature.

Compress radial and ulnar arteries and release to evaluate skin color. To perform the Allen test, the radial and ulnar arteries are occluded until the hand is pale and then released to evaluate hand color, which determines collateral circulation to the radial artery if the artery is injured during the collection of an ABG blood sample. The PN can assist the nurse by performing the Allen test (A), which should be done before each arterial puncture. A tourniquet is not used for arterial puncture (B). The arterial puncture site is compressed for 5 minutes, not (C). The ABG specimen is stored on ice, not (D), during transport for analysis.

The practical nurse (PN) is assessing breath sounds of a client who has spontaneous respirations after an endotracheal tube (ET) insertion. The breath sounds are absent on the left side. What action should the PN do? Place the client in high Fowler's position. Deflate the ET cuff to enhance air flow. Contact the nurse in charge immediately. Apply an oxygen collar to endotracheal tube.

Contact the nurse in charge immediately. A complication of endotracheal intubation is advancement of the tube into the right main stem bronchus, which does not aerate the left lobes. The PN should contact the nurse (C) so the ET can be repositioned. (B) is ineffective in aerating the left lung fields if the ET has been advanced into the right stem bronchus. (A and D) can be implemented after the ET is repositioned.

A client who is 2-days postoperative for abdominal surgery has a nasogastric tube (NGT) to low continuous suction. The client tells the practical nurse (PN) that his mouth is so dry, he has been drinking water to quench his thirst. Which potential imbalance should the PN monitor for development in the client? Fluid volume excess. Metabolic alkalosis. Hyperkalemia. Hypercalcemia.

Metabolic alkalosis. The continuous gastric suction and the fluids the client drank increases the washing out gastric hydrochloric acid, which places the client at risk for metabolic alkalosis (B). (A, C, and D) are unlikely with gastric suction.

Which action should the practical nurse (PN) implement for a client who is having a liver biopsy? Document bowel sound assessment prior to biopsy. Keep the client NPO for 8 hours before the procedure. Place the client on the left side after the procedure. Monitor for signs of dyspnea after return from biopsy.

Monitor for signs of dyspnea after return from biopsy. Biopsy of the liver may cause a pneumothorax due to the liver's proximity to the lung. After the biopsy, the client should be monitored for signs of dyspnea (D). (A and B) are not required before the biopsy. The liver is located in the upper hypochondriac region, so the client should be placed on the right side, not (C), to facilitate external compression to the puncture site.

A client who received graphs for a full-thickness burn of the right arm is admitted to the rehabilitation unit. Which action is important for the practical nurse to reinforce with the client to prevent long-term complications? Exercise the affected arm everyday. Drink 2 liters of fluid per day. Encourage visitors to wash hands. Request analgesics as needed.

Exercise the affected arm everyday. Exercise (A) is an important component in the rehabilitation stage following a severe burn to prevent contracture formation, which impairs normal function of the muscle and joints of the arm. Although fluids (B) are important in the initial stage after a severe burn, it is not a key need in rehabilitation in preventing long-term complications. (C) is important in the prevention of infection. (D) may be indicated during convalescence, but exercise is vital to ensure range of motion and prevention of long-term effects of contractures.

A client who is experiencing an acute asthma attack is receiving rescue medication. The practical nurse (PN) reviews the client's history to determine the client's respiratory function over the past few months. Which device results should the practical nurse review to obtain data that measures the client's personal best respiratory function? Pulse oximeter. Chest x-ray. Incentive spirometer. Peak flow meter

Peak flow meter

A client presents to the clinic complaining of severe stabbing pain in the epigastric region that radiates to the mid-back area. Which finding indicates to the practical nurse that the client should remain NPO? Amylase and lipase levels are 3 times the normal value. Alanine aminotransferase (ALT) is 4 times the normal value. White blood count is 14,000 mm3. Serum potassium is 3.2 mEq/L.

Amylase and lipase levels are 3 times the normal value. Pancreatitis is confirmed by amylase and lipase levels that are elevated 2 to 3 times the normal value (A). Clients with pancreatitis should be kept NPO, which allows the pancreas to rest. An elevation in ALT levels (B) is characteristic of liver disease. WBC elevation (C) indicates infection. A low serum potassium level (norm is 3.5 to 5.5 mEq/L) indicates hypokalemia. Although (B, C, and D) require further assessment by the healthcare provider, they do not require an NPO status.

The practical nurse (PN) is completing focused assessments for four clients. Which client finding should be the PN's first priority? A client with bronchitis who is short of breath and can only speak in phrases. A client with emphysema who has a pulse oximeter 90% and 101.1°F temperature. A client with asthma who is coughing and has distant auscultated breath sounds. A client with pneumonia who is wheezing and expectorating green sputum.

A client with asthma who is coughing and has distant auscultated breath sounds. The priority finding is compromised air flow manifested by diminished or absent breath sounds (C) which is indicative of atelectasis of an affected lobe due to mucus obstruction. (A and B) are expected findings for clients with chronic obstructive pulmonary disease (COPD) and are not as emergent as the client with obstructed air flow and poor oxygenation. (D) requires treatment, but the priority is (C).

The practical nurse is caring for a client who is admitted with signs of possible acute brain attack (stroke) three hours ago. The client's blood pressure is 170/96, regular radial pulse 76 beats/minute, respirations are nonlabored at 11 breaths/minute, and a SpO2 of 99%. What action is most important for the PN to implement? Call healthcare provider for antihypertensive. Assess the client for Brudzinski's sign. Continue to monitor client's blood pressure. Monitor client's IV fluid intake and urine output.

Continue to monitor client's blood pressure. The goals for management of a client with a suspected stroke is continuous monitor of blood pressure (C) and neurological deterioration to determine eligibility for reperfusion therapy. Antihypertensives are indicated if the systolic is 180- 230 or diastolic is 105-140, so (A) is not indicated at this time. (B) is most likely associated with meningeal irritation related to meningitis. Although (D) is a basic component of client care, the priority is monitoring the client's blood pressure.

A client with a ventriculoperitoneal shunt has large bruises on the forehead and arm. The practical nurse (PN) at the outpatient clinic determines that the client received the bruises accidentally while walking through the doorways at home. What action should the PN take? Evaluate the client's pupillary response to light. Encourage the client to wear a helmet. Determine if the client is a victim of physical abuse. Ask if the client is experiencing tinnitus.

Evaluate the client's pupillary response to light. A malfunctioning ventriculoperitoneal shunt can cause increased intracranial pressure (ICP) that results in neurological changes, such as poor depth perception that cause self injury while walking through doorways. Assessing for pupil equality, shape, reactivity to light (A), and other neurological assessments should be implemented. Although (B) may be encouraged for clients with a shunt or who have frequent seizures, the priority is to assess for signs of ICP. The client is most likely experiencing a shunt malfunction, not physical abuse (C). Ringing in the ears (D) is not a classic neurological symptom finding of ICP.

A client who is 12-hours postoperatively for a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) is refusing to turn and perform postoperative leg exercises. What action should the practical nurse take? Apply bilateral compression stockings (TEDs). Reinforce teaching concerning postoperative complications. Allow the client to refuse turning from side to side. Review medical record for recent analgesic administration.

Apply bilateral compression stockings (TEDs). Following major abdominal surgery, such as TAHBSO, prophylactic measures to prevent deep vein thrombosis (DVT) is a priority, so TEDS (A) should be applied to the client's legs. The client is mostly likely not receptive to reinforcement of teaching (B) in the immediate postoperative period. Although the client has the right to refuse to follow instructions (C) and may need to be medicated (D), the routine use of TEDS is valuable in the prevention of blood pooling in the lower extremities.

A male client with a chest tube and a three-chamber water seal drainage system calls the practical nurse (PN) to the bedside and says his chest tube (CT) is not working. The PN observes that the client's respiratory effort and breath sounds are normal. Which action should the PN implement? Clamp CT to prevent air entering the pleural space. Milk the CT to clear any tissue or blood clots. Place a petroleum dressing over insertion site. Observe the water-seal chamber for bubbling

Observe the water-seal chamber for bubbling Assessment of the water-seal drainage system should be implement to determine if normal fluctuation of the water level in the water-seal chamber is occurring or if continuous bubbling is present (D), which is indicative of an air leak. Clamping the CT is not recommended (A) but may be necessary if the water seal drainage system is damaged. Chest tubes should not be milked (B) or stripped because this action increases intrapleural pressure. (C) is implemented if the chest tube becomes dislodged, which is not evident at this time.

Which instructions should the practical nurse (PN) reinforce with a client who is preparing for discharge after placement of a permanent pacemaker implant? (Select all that apply.) Request the use of special hand scanning at airports. Avoid using cellular phones for long periods of time. Do not lean against the car while the engine is running. Keep the regularly scheduled follow-up appointments. Ingest a consistent amount of leafy green vegetables.

Request the use of special hand scanning at airports. Keep the regularly scheduled follow-up appointments. Do not lean against the car while the engine is running. A client who has a permanent pacemaker should receive reinforcement of instructions that prevent malfunction of the pacemaker (A and C). The client should implement (D) to ensure that no complications have occurred with the pacemaker. (B and E) are not indicated for a client with a pacemaker implant.

The practical nurse (PN) is caring for a group of clients on a telemetry unit. Which client requires immediate follow-up by the PN? A client with second degree heart block who is receiving digoxin (Lanoxin). A client with chronic obstructive pulmonary disease who is taking oral glucocorticoids. A client with multiple premature ventricular contractions (PVC)/minute after receiving atropine. A client who is trembling after a dose of epinephrine is given for an acute asthma episode.

A client with multiple premature ventricular contractions (PVC)/minute after receiving atropine. A client who is experiencing multiple PVCs/minute (C) is at risk for ventricular fibrillation (VF) and requires immediate follow-up and treatment. Digoxin slows the heart rate by decreasing the rate impulse conduction through the AV node, which is contraindicated in heart block (A), but the client who is at risk for impending VF is the priority. The PN should continue monitoring (B and D) for other side effects of glucocorticosteroids and epinephrine, such as trembling (D), which are not life threatening.

On admission, a client with an acute myocardial infarction receives a thrombolytic, aspirin, and IV heparin. Which finding indicates to the practical nurse (PN) that the client is having a therapeutic response to the medication? Lungs clear bilaterally and heart tones regular in rate and rhythm. Ankle edema decreased from 3+ to 1+. Activated partial thromboplastin time (APTT) results 2 times the control. Platelet count greater than 150,000/mm3.

Activated partial thromboplastin time (APTT) results 2 times the control. Acute Coronary Syndrome (ACS) protocol includes the administration of thrombolytics, aspirin, and IV heparin, which prolongs the activated partial thromboplastin time at the therapeutic range that is two times the control value (C). This protocol of medications has no therapeutic effect on lungs sounds (A), heart rate or peripheral edema (B), or platelet count (normal platelet count is 100,000 to 400,000/mm3) (D).

A male client who was recently diagnosed with Guillain-Barré syndrome (GBS) tells the practical nurse (PN) that the paralysis of his lower extremities is climbing. What is the most important intervention for the PN to implement? Monitor respiration depth. Protect lower extremities from injury. Determine bilateral muscle strength and movement. Administer moisturizing eye drops.

Monitor respiration depth. Guillain-Barré syndrome ascends progressively, starting at the feet, at an unknown rate of paralytic involvement. The most important intervention is to monitor for paralysis that may involve the diaphragm, so the rate and depth of respirations must be monitored (A) to determine adequate ventilation. Breathing takes priority over potential injury to the lower extremities (B). (C) is an expected finding. (D) should be provided if paralysis involves the cranial nerves, but the priority is addressing ABC (airway, breathing, circulation).

Two days after a small bowel resection, a male client reports tingling of fingers and toes and feels dizzy. The client's nasogastric tube (NGT) is draining per low intermittent suction, and the practical nurse (PN) suspects the client has a fluid and electrolyte imbalance because he has been taking oral ice chips PRN. Which assessment finding should the PN report when monitoring the client? Distended neck veins and bounding pulse. Elevated pulse and dysrhythmia noted on telemetry. Feelings of heaviness and pain to the legs. Decrease in blood pressure baseline and headache.

Elevated pulse and dysrhythmia noted on telemetry. Nasogastric suctioning that increases the loss of gastric secretions that are diluted by the client's oral intake of ice chips contributes to fluid and electrolyte imbalances and can cause a metabolic alkalosis. The client's cardiovascular function should be monitored for signs an elevated pulse and cardiac dysrhythmias (B) related to fluid loss and potassium imbalances. (A) describes symptoms of fluid volume excess, not loss. Deep vein thrombosis typically causes heaviness in the leg and unilateral pain (C). (D) are signs related to metabolic acidosis, not alkalosis.

Which finding is an early indication that a recently applied leg plaster cast is causing compartment syndrome? Client states the cast is warm. Pain rated "7" at fracture site. Paresthesia. Pulselessness.

Paresthesia Nerves are sensitive to excessive pressure which causes a tingling sensation, paresthesia (C). It is an expected finding for a plaster cast to initially feel warm (A), which is due to an exothermic reaction of the wet plaster. Pain after a fracture is common (B), but pain characteristic of compartment syndrome is unrelenting pain despite analgesia or with passive movement. Although obliteration of the pulse (D) is a sign of compromised circulation, this is a late sign occurring after a client experiences a loss of sensation or paresthesia.

A client with heart failure (HF) takes a daily tablet of furosemide (Lasix) and lisinopril (Zestril). Which finding during the clinic visit should indicate to the practical nurse that the client's condition is worsening? Dizziness when changing position. Reports urgency with urination. Sharp chest pain with arm movement. Sleeps with two additional pillows.

Sleeps with two additional pillows. Clients with worsening HF often require additional pillows to sleep comfortably at night (D) resulting from a deceased cardiac output that causes fluid backup into the alveoli when supine. Since ACE inhibitors can cause postural hypotension, clients should be advised to change positions slowly (A). Lasix can cause urinary urgency (B) when the bladder fills as a result of diuresis. (C) is likely related to muscle strain because the pain is movement-induced and not related to cardiac hypoxia.