Hesi

A client is scheduled for an electroencephalogram (EEG). What will the practical nurse instruct the client about this diagnostic test A?

you will have electrodes placed on your scalp on your scalp during the test

Which group of population the nurse assesses for scoliosis

young girls

Prior to administering a prescribed tube feeding to a client with a gastrostomy tube why would the practical nurse aspirate for gastric residual volume?

the evaluate the amount of gastric emptying

A client is admitted to a private room tells the PN that the insurance carrier will not pay for the private accommodations. What would the PN resound to the client ?

the insurance carrier will cover the cost of the room if there are no semi private rooms available

The PN assesses an improvement in a clients mood after taking a prescribed antidepressant medication for a week. What does this finding suggest to the nurse?

the medication is effective

this will be a prioritizing question of which patient to see first

the patient with bright red drainage coming out of anus after colonoscopy and polyp

a picture of someone opening an ampule.

the person should be using an alcohol pad or a pad to break open the ampule so when you break the ampule glass doesn't break the ampule

A client who is preceded bed rest asks why PROM exercises are being done three times a day. What explanation would the PN provide to this client?

the will ensure that your joints are limber when you begin walking

Single mother of a child with head injury comes crying to the clinic what should the PN tell her?

this must seem overwhelming to you right now

know which foods are high in b12

...organ meats, liver kidney, sardines

Asks if he can give asprin to his 8 year old.

"it is better to obtain children acetaminophen to prevent possible side effects from the aspirin "

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include in the assessment of this client?

"what are the voices uttering?"

The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments

-A client who is admitted with a suspected ruptured appendix -A client who is post-lumbar puncture is reporting a severe headache -An older male adult with Alzheimers who wanders out of his room -A postoperative client who needs reinforcement of discharge instruction

...

-Assess the condition of the IV site -loosen tape that secures the existing tubing -remove existing tubing and spike new tubing into bag -clamp the IV catheter and attach the new tubing -unclamp the tubing and IV catheter and begin the infusion

A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home?

-The 6-year old son hits his younger sister during the interview -the 10-year old daughter has circular burns on her trunk and legs -the 3-year old has multiple bruises on the chest and both legs

The PN is making shift assignment at an extended care rehabilitation...assign to the UAP.

-Toileting assistance for a client receiving therapy after a total hip replacement -daily skin care for a client with a descending double barrel colostomy -morning care for a client with a staph wound infection

hyperparathyroidism

-administer furosemide (lasix) -monitor positive signs of Trousseaus Chvosteks sign -monitor for changes in the voice pattern and hoarseness

UAP delegations

-applying a condom catheter -applying a hearing aid -applying cold packs -assisting to deep breath and cough -blood glucose monitoring -collecting specimens -emptying drainage containers -giving a sitz bath -vaginal douche -recording intake/output -removing a Foley catheter -taking specimens to the lab

hypoparathyroidism

-can occur following a thyroidectomy because of the removal parathyroid tissue -provide high calcium and low phosphorus -reinforce taking vitamin d with aiding in the absorption of calcium monitor for signs of hypocalcemia including tetany and numbness and tingling in the face

know postoperative care for parathyroidectomy

-complications are airway obstruction and hypocalcemia -be alert for tetany a tingling around the mouth and fingers and can be treated with calcium keep head elevated

A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? select all that apply

-remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application -place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site -pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads

The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What...

-why the fluid measurements need to be recoded -which food types are included when measuring fluid take -what container to use for the most accurate measurement

A client is prescribed lorazepam (Ativan) 0.5 mg oral suspension every 6 hours as needed for anxiety. The medication is available as 2 mg/mL oral suspension. How many mL of the medication will the PN provide for each dose?

0.3 mL

A client prescribed to receive terbutaline sulfate (Brethren) 0.25 mg subcutaneous injection three times a dat at 6 hour intervals. The medication is available as 1 mg/mL. How many mL of the medication will the PN provide to the client for one day?

0.75

A client is prescribed cefazolin sodium (Ancef) 300 mg intramuscular injection every 8 hours. The PN has a 500 mg vial of medication that will be reconstituted with 2 mL of sterile water for injection. After reconstitution the volume of medication will be 2.5 ml. How many ml of medication will the PN provide in one dose for the client?

1.5

The PN is caring for a client recovering from a transurethral resection of the bladder for prostate hypertrophy. The client has an indwelling urinary catheter and is receiving continuous bladder irigation of sterile normal saline at 100 mL per hour. the health care provider has prescribed to reduce the irrigation to 50 ml/hr if the clients output measurement is equal to 550 mL for 4 hours at which point would the PN reduce the clients bladder irrigation

1000 output measurement 550 mL

A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy?

1700

A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ?

Act as the clients advocate when discussing the issue with the HCP

A client is prescribed erythromycin (E-mycin) 400 mg oral suspension every 4 hours. The medication available is 100 mg/5 mL. How many mL will the practical nurse administer to the client for each dose

20 mL

A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice daily in equal dosages.How many tablets should the PN...

3

After three weeks of antibiotic therapy, a child who weighs 55 pounds develops painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg daily. How many mg should the PN administer to this child?

500

a client is diagnosed with respiratory acidosis. What blood pH value will the PN assess when reviewing the clients arterial blood gas results?

7.29

An obese client asks why a high-protein diet will not help reduce her elevated cholesterol level. What would the practical nurse respond to this client?

A high protein diet consist of meat, poultry, and dairy products which are all high in cholesterol

An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide?

A history of untreated gonnorhea can lead to PID

A school-aged child is given a varicella zoster immune globulin injection. The practical nurse realizes this client has which chronic illness?

AIDS

Flow Sheet Date Hr 1 Hr 2 Hr 3 Pad count 2 3 2 Urine output 45 mL 35 mL 40 mL TAB 3 - Laboratory Results Date Laboratory Test Results Bilirubin level newborn 14 mg/dL Indirect Coombs' test mother Negative Direct Coombs' test newborn Positive

Administer Rh immune globulin

The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond?

Affirm the importance of rest to promote liver healing

when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication?`

An older client with a stroke who is febrile and confused

Based on the principle of asepsis the PN should consider which situation to be sterile?

An open Foley catheter kit set up on a table at the PN waist level

A client with a fever is diaphoretic and the linens are saturated. After assessing the clients vital signs, which action would the PN take?

change the bed linens

...the partner refuses to go. The PN suspects the injuries may be the result of...

Arrange to take the client to the operating room holding area for privacy

An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete?

Ask about occurrence and frequency of nosebleeds

the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts?

Begins to show signs of improvement

A client has an infiltrated intravenous access device in the right arm. To evaluate blood flow to this extremity, which arteries will the practical nurse assess? (Select all that apply.)

Brachial radial ulnar

When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take?

Close the door and report the finding to the charge nurse

Six hours after removing a clients indwelling urinary catheter the client has not voided ad is expressing discomfort from a distended bladder. What action would the PN take?

Complete a bladder scan

An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate...

Consecutive evening serum glucose readings of >260 mg/dl

The PN assesses a moon-shaped face and muscle wasting in a client receiving dexamethasone (Decadron). What will these manifestations suggest to the PN?

Cushings syndrome

Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120 beats/min. Based on this finding what action should the PN take?

give the medication and document the heart rate

a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first?

Determine the amount of water and exact time it was taken

The PN is reviewing the state nurse practice act. What information will be included within the document?

legal requirements for PN

The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take?

Encourage the client to continue the dietary changes she has made

A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take?

Ensure that all the areolar tissue of the nipple is in the infants mouth.

When preparing to apply a new ostomy bag for a client's colostomy, why will the practical nurse measures the stoma size?

Ensure the bag fights tightly near the stoma

A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client?

Explain risks associated with using herbs instead of the prescribed antihypertensives.

The hearing of ringing in the ears what medication should be reported to the Health provider ?

Gentamicin

pregnant lady reports greenish discharge from vagina nurse should advise the to test for

Gonorrhea

The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client?

Has increasing episodes of urinary incontinence

The practical nurse is reviewing laboratory values for assigned clients. Which value would the practical nurse report immediately to the health care provider? ESTRICT

Hemoglobin level 7.0 mg/dL

A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information?

History of alcohol and tobacco use

Because of staffing shortages the charge nurse assigns a PN to perform a skill which the PN is not yet certified to perform what is the best response by the PN?

I am uncomfortable performing a skill which I am not certified

when the PN attempts to assist an 18-year old female client with mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN "get out of here! Ill get up when I'm ready!" which response is best for the PN to make?

I know you feel very angry about the pain of ambulation but this is a necessary part of getting well

signs of hypothyroidism

lethargic poor appetite dry cool skin sluggish

A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement?

Maintain system integrity and to promote lung reexpansion

A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. the morning the PN observes that he...Which intervention is most important for the PN to implement?

Measure appropriate vital signs

The Glasgow coma scale is being used to monitor a client in the critical care unit. The scale is used to evaluate what client status?

level of conscious

A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this medication?

Monitor the client for nausea or vomiting following the treatment

A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first?

Obtain prescribed calcium gluconate for tetany

LPN finds schizophrenic patient sitting and talking alone

PN should ask if patient is hearing voices

The pn determines that a client with cirrhosis is experiencing peripheral....take?

Protect the clients feet from injury

During morning rounds a client is admitted with OCD is in the...of the same table. What intervention should the PN implement when approached?

Provide time for the behavior then guide the client to other activities

fire starts what to do?

Remove patient activate the ALARM close door extinguisher

which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

Report any food injury or sore that does not readily heal

A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve?

Self-actualiztion

The lips and mucous membranes of an African-American client are dusty in color. What does this assessment finding suggest to the practical nurse?

low oxygen level

A client with hypertension complains of a persistent dry cough. The PN should tell the client that this is a common side effect of which daily medication?

Quinapril

A client with a chest tube attached to a water sealed drainage system has had 400 mL of drainage over the last 8 hours. After morning care the client was repositioned and the chest tube drainage has been 0 ml for the last 2 hours. What action would the PN take at this time?

Reposition the client.

A client has had a procedure that will result in scarring of the cervix. How will the effects of the procedure impact the client's ability to achieve pregnancy in the future?

Restrict the fertilization of the ovum

Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream

A client who received in vitro fertilization has an examination to learn that the procedure was unsuccessful. The client is sitting quietly in the examination room and begins to cry. Which action would the PN take at this time?

Sit with the client

The PN is assisting an unsteady client to ambulate from the bed to the bath...client loses balance and falls onto the bedside table. what action should the PN take first?

Stay with the client and call for assistance

What equipment will the PN ensure is present before delegating the task of feeding a client on aspiration precautions to UAP?

Suction

while assessing a school age child about a new arm fracture the PN learns that the clients explanation for the injury is different from the one provided by the mother. What does this information suggest to the PN?

T he client is a victim of possible child abuse

When walking with an older client the practical nurse supports the client's upper torso. Why is the upper torso the center of gravity in an older client?

The hips and knees flex causing a stooped posture

A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome?

The left foot is warm to touch with a palpable dorsals pedis pulse

The PN is with a client when the health care provider explains that the..tumor.Later in the morning the client asks the PN "What do the letters T,N,M: star for?

The letters stand for tumor size, node involvement, and metastasis

Why would the PN schedule physical therapy in the morning for a client with myasthenia gravis?

The muscles are strongest in the morning

A client recovering from a breast biopsy is told that the lesion is classified as being T1N1M0. What will the practical nurse explain this classification as being to the client?

There is one lymph node involved

A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort?

Wear a supportive bra at all times

After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention?

a client who is trembling and has a glucose level of 50

signs of hyperthyroidism

apprehensive agitated and irritable budging eyes (GRAVES DISEASE) weightloss poor tolerance to heat tachycardia

A female client from a non-English speaking culture tells the male practical nurse that she will not perm it him to bathe her. The client has bowel incontinence and has been diaphoretic from a fever. Which action would the male practical nurse take?

ask a female PN to provide the client with a bath

An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dL . She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse?

aspirin

While measuring an orthostatic blood pressure the client becomes dizzy. What would the PN do?

assist the client to site down

The PN is planning care for a client who has generalized tonic clonic seizures and is vomiting and having frequent diarrhea stools. to reduce the risk of injury to this client which nursing measurements should the PN implement?

axillary temperatures and padded side rails

Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinenece

maintain standard precautions

The PN is caring for a client in bucks tract what is the priority goal for the client in traction?

maintain straight body alignment

A client with an external urinary catheter is complaining of pain. What would the practical nurse do to help this client?

remove the external device

Why would the practical nurse count a client's apical heart rate for a full minute?

the clients heart rate is irregular

common side effects of iron and are normal if the client report

black stool

baby of diabetic mother was born jittery and blood glucose is 40 mg/dL what should the nurse implement?

breastfeeding or milk feeding the baby

An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN?

weights are touching the foot of the bed

when should a person use additional birth control precautions?

when taking antibiotics for an infection

A new mother asks the pn about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond?

caput succedaneum will be absorbed and causes no problem

Patient has carotid endarterectomy how to observe for signs of bleeding?

check area around the neck and elbow

When repositioning patient the nurse observes wound with a foul odor the nurse should...

check the white blood cell count

The practical nurse is documenting the health history of a client who smokes one pack of cigarettes per day. Which client manifestation may be directly related to this lifestyle action?

chest pain that radiates down the left arm

Which picture of nailbeds indicate hypoxia?

choose the one that has a bump right below the nail bed

The nurse assesses a child in 90-90 traction. Where should the nurse assess for signs of compartment syndrome? the picture will show a child in traction with left left in traction

click on the toes of the elevated leg

The charge nurse is making client care assignments on a busy medicalsurgical care area. Which client would be appropriate to assign to the practical nurse?

client recovering from a stroke needing subcutaneous heparin and gastrostomy feedings

The charge nurse is making assignments for client care. Which client would be assigned to the PN for the assessment?

client with confusion and sundowner syndrome

The PN contacts a clients health care provider to report that a client is refusing medication and other treatments prescribed for a health problem. Which moral principle is the PN supporting at this time?

clients right to autonomy

How should the PN assist the client to provide sputum sample?

coach the client to take deep breaths and cough deeply to mobilize secretions

A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information?

confirm that the desired effect of the medication has been achieved?

When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take?

contact the medication nurse to clarify the findings

A client is prescribed dexamethasone (Decadron) 8 mg by mouth with breakfast. The medication is not in the drwer.

contact the pharmacy and ask that the medication be delivered now

the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding?

gastric residual volumes

While the PN and UAP are turning a client with an abdominal incision, the clients incision eviscerate. Which task is best for the PN to assign to the UAP?

gather supplies

The practical nurse provides an older client with a prescribed narcotic pain medication. Why would the practical nurse encourage the client to drink more fluids while taking this medication?

decrease the onset of constipation

the PN is preparing to remove an indwelling urinary catheter in a female client. Which action would the PN perform first?

deflate the balloon on the catheter

A client has refused to bathe for several days and tells the practical nurse it is because unlicensed assistive personnel are "rough" during the bath. What would the practical nurse do?

delegate the task to other UAP

Which site should the PN use when administering RHO D

deltoid

Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client?

deltoid

A 16 year old client is preceded to receive 1.0 mL of an intramuscular injection. Which sites would the PN consider to administer this medication?

deltoid ventrogluteal

The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement?

demonstrate to the UAP how to approach the client from the clients left side

A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next?

determine the level of consciousness

While administering morning care to a client, the UAP informs the PN that the clients lower extremity wounds are leaking bloody drainage. What action would the PN take?

direct the UAP to accumulate wound dressing supplies

A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client?

direct the client to obtain immediate transportation to the emergency center

There was a question about a patient going into surgery who has diabetes do you give them insulin or not?

do not give a patient insulin before going into surgery

HIV patient received Rifampin, Gentamicin and Isoniazid which one will cause ringing of the ear?

gentamicin

A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take?

give 4 ounces of apple juice

what can cause hypertension in. client

eating salty snack and chewing tobacco

A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal ?

emphasize the importance of active foot flexion

The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the clients urine is the color of dark tea. What action should the PN take?

encourage increased oral fluid intake

to lower fear of separation for 2 year old nurse can

encourage parent to move in

A male client who was admitted with gangrene of the right lower extremity is confused ad his wife refuses to sign the operative permit for an above the knee amputation. What action should the PN take first?

encourage the clients wife to express concerns

The PN observes a family member provide passive ROM to a client paralyzed upper extremity, The family member is supporting the client elbow by holding above and below the joint through ROM. Which action would the ON take after making this observation?

encourage the family member to continue because the procedure is being done correctly

A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks. What should the nurse tell the mom?

ensure that all the areola tissue of the nipple is in the infants mouth

on admission to the medical unit a client who is homeless and has a history of HIV with persistent cough?

erythema and indurations of 5mm at site

While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for?

expected finding

The spouse of a hospitalized client asks the PN for acetaminophen for a tension headache. Which action should the PN take?

explain that medication can only be provided to clients

28 year old client is in active labor and complains of a cramp in her leg. what intervention should the PN implement ?

extend the leg and flex the foot

A 28-year old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement?

extend the leg and flex the foot?

A client is having a lumber puncture. in which position would the PN assist the client into assuming?

fetal position

A client is admitted for treatment of diabetic ketoacidosis. Which manifestation will the PN assess in this client?

fruity breath odor

There was a picture of SCD (sequential compression device) placement and picking the picture with the correct placement

google some pictures of what placement looks like. SCD should be placed on calf than flat side folded first around shin and than part with 3 folds over the flat. Picture will make more sense

The PN is caring for a client with atrial fibrillation. What would be an expected finding when assessing this client?

heart rate 88 and irregular

A client is admitted for observation after experiencing a TIA

high risk for injury

A client with multiple sclerosis has developed a bladder infection. What would the PN identify as a possible cause for this infection?

immunosuppressant therapy

Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first?

implement complementary pain relief methods

A 40 year old client has obtained a baseline mammogram. When would the PN recommend that the next mammogram be performed?

in 1 year

during a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0bmL q/L. Which action should the PN recommend to the client based on this finding?

increase intake of dried peaches and apricots

The PN has identified the howling statement as a desired outcome for a client "client will report effective pain management when using analgesic medication every 6 hours as prescribed." This outcome statement would be appropriate for which client problem?

ineffective pain management

The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next?

initiate the urine stream?

patient with OCD states that he doesn't know what to do because people are laughing at him while they don't understand him and he cannot take this anymore

inquire for idea of suicide

new mother says she thinks her baby head looks funny

instruct the mother that this is normal and round head shape will come back after 7-14 days

The PN is assessing a clients home environment for safety> Which action would the PN suggest to reduce the risk of falls in the home?

instruct to keep all walkways and steps clear of clutter

The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care?

interventions to decrease emotional stress

The practical nurse is caring for a client with an allergy to shellfish. Which diagnostic test would be impacted by this client's allergy?

intravenous pylegram, cerebral angiography

When preparing to measure a client's blood pressure the practical nurse places the client's arm at the level of the heart. What is the importance of this action?

it ensures the most accurate reading

The practical nurse positions a client with face and neck burns supine with the neck extended and resting on a rolled towel. Why is this position beneficial to the client?

it maximizes neck and face function

The practical nurse is caring for a postpartum client. Based upon the information provided, which action would the nurse take? TAB 1 - Health Care Provider's

iti g

photo of chest and locating apical HR

just below the left nipple

The PN is reviewing actions for a mother to take to prevent her toddler from being injured in the home. What will the PN emphasize with this mother?

keep poisonous and other materials locked away

While inserting an indwelling urinary catheter into a female client the catheter slips into the clients vagina. What would the PN do?

keep the catheter in the vagina and insert a new catheter through the urethral meatus

After using an intermittent urinary catheter to drain the bladder of a postpartum client the practical nurse determines that the client's fundus is boggy. What action would the practical nurse take at this time?

massage the fundus

A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client?

measure all emeisies accurately

A client with schizophrenia is withdrawn isolates himself in the day room and answers questions with one or two word responses which intervention is most important ?

measure appropriate vital signs

A client is prescribed a treatment in which the process of filtration will be used. How will the practical nurse explain this cellular transport mechanism to the client? p

mechanical pressure forces water and solutes through the membrane

Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the PN nurse observe when administering direct client care?

minimal time maximum distance and protective shielding

The PN is caring for a client with pneumonia. Why will the nurse ambulate with the client every 2 hours while awake?

mobilize secretions

The PN overhears a female client with Cushings syndrome tell her family in a...very loud and angry voice to leave her room and not come back. The response by the PN is baed on recognizing which common manifestation of the syndrome?

mood alterations

A client's respiratory rate is assessed as being 8 per minute. Which medication would the practical nurse suspect as causing this client's reduced respirations?

morphine sulfate

A client is prescribed losartan (Cozaar) for high blood pressure> What will the PN remind the client do to prevent sudden dizziness?

move slowly when changing position and ensure adequate fluid intake.

A client is diagnosed with with hyperthyroidism. Which symptoms should the PN expect this client to exhibit?

muscle cramping and dry flushed skin

A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor?

neuro-vital signs related to bleeding and intracranial pressure

A client with a compound fracture of the left ankle is being discharged with a below the knee cast....PN provide to the client prior to discharge?

never scratch under the cast

At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN take next?

note the most recent white blood count

A client with type 1 diabetes mellitus has a morning fasting blood glucose level of 70 mg/dL. Which action would the practical nurse take?

nothing since this is considered a normal blood glucose level

A client with a bee sting has a respiratory rate of 28 and an oxygen saturation level of 80% on room air. What action would the practical nurse take at this time?

notify the HCP and prepare to administer O2

A client being treated with prednisone (Deltasone) for a skin infection tells the PN that the medication was stopped a few days prior because the rash disappeared. What action would the PN take at this time?

notify the HCP that the client did not complete the medication

Patient states that he does not want to have pancreas cancer so for now he will switch to smokeless devices

nurse should instruct risk about smokeless devices also

The PN views the mid-line episiotomy of a client who reports pain in her stitches. What action should the PN take first?

observe suture line for separation and hematoma formation

The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement?

observe the appearance of the urine in the drainage tubing

the PN provides cold packs to the perineum of a postpartum client with perineal hematoma. What will the PN do to evaluate the effectiveness of this action?

observe the hematoma for changes in size

Client with Hungtingtons disease starts jerking around while the family is there what should the PN do?

offer emotional support to the family

A client recovering from a stroke is learning how to use a cane. How should it be placed?

on the stronger side of the body

the PN plans to evaluate an adults response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. which data should the PN obtain to evaluate the therapeutic effectiveness of this medication?

pain scale level during walking

During morning report the PN learns that an assigned client has phlebitis from an intravenous access device. What manifestations will the PN assess in this client?

palpable cord along the vein

photo of a blood pressure cuff on a clients arm. What would you tell the person

palpate the brachial pulse which is on the inside of the arm

To obtain an estimate of a clients systolic blood pressure, what action should the PN take first?

palpate the clients brachial pulse

Which client care activity would a practical nurse delegate to unlicensed assistive personnel?

passive ROM exercises to a client with a stroke

The nurse is caring for a young adult client who uses intravenous drugs and has unprotected sexual intercourse with several partners. Which health promotion action would the practical nurse recommend for this client?

periodic HIV testing

After applying alcohol based hand rub to the palms of the hand and rubbing paps together what action should the PN take next?

place hands on top of each other and interlace fingers

A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process?

plasma protein losses resulting in decreased oncotic pressure within the vessels

A 3-year old child returns to the pediatricians office for a postoperative visit after having...procedure. The PN should expect to observe which behavior that indicates...

plays doctor and nurse with the dolls

A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment?

position client in left lateral position to inspect perianal area for fissures or sacs

The PN is caring for a client whose urine drug screen is positive for...exhibit during cocaine withdraw

powerful craving for more

A 24-year-old client is experiencing amenorrhea. For which health condition will the practical nurse focus when assessing this client?

pregnancy

The practical nurse writes the care plan of a client with partial-thickness burns "perform hand hygiene before and after providing care." What is the purpose of this action?

prevent infection

Immediately after birth, which nursing intervention has the highest priority for the newborn infant?

preventing heat loss and neonatal cold stress

The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectivesnn, which laboratory values should the PN monitor?

prothrombin time, Sputum culture and sensitivity, white blood cell count.

A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug?

provide oral care

The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dL to the nurse. What action should the PN implement next?

provide the client with a glass of milk and crackers

.A client recovering from a myocardial infarction is demonstrating pinktinged frothy sputum. What does this manifestation suggest to the practical nurse?

pulmonary edema

The practical nurse demonstrates to a client how to inhale through the nose with the mouth closed and exhale through pursed lips. What is the practical nurse reviewing with the client?

pursed lip. breathing

patient with dementia is admitted to the unit and is very agitated during the night

put patient in room next to nursing station

A client is at a high risk for injury. Which action would the PN take to ensure for the clients safety?

raise the side rails and provide the client with the call light for assistance

A client recovering from surgery to the fibula has bleeding on the cast. The PN outlines the border of bleeding to serve at a baseline. Which action would the PN do next?

recheck the cast within the next 15 minutes

During morning report the PN learns that an assigned client has phlebitis from a intravenous access device. What will the PN observe in this client?

redness, warmth, and edema of the site

An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ?

reinforce the need for extra rest periods and plenty of sleep

The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement?

report the findings to the charge nurse

...Befor her mentural period the PN determins the client is not pregnant.... what action should the PN take.

request return visit for examination after her period when hormones are lowest

the PN is planning to assess a clients kidneys. What is the orientation of these organs within the abdominal cavity?

retroperitoneal to the perineum

A client reports feeling numbness and tingling in extremities. What action should the PN implement?

review the clients serum electrolyte levels

when assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. he also has a history of gastroesophogeal reflux disease and depression. which interventions is most important for the PN to implement?

review the clients use of over the counter (OTC) medications

The PN is caring for a client with an enlarged liver. When assessing this client on which part of the abdomen will the nurse focus?

right upper quadrant

When the PN strokes the right side of a newborns cheek the baby turns the head towards the side that is stroked and opens opens the lips. Which reflex is the PN assessing?

rooting

While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information....

screening for tardive dyskinesia

When applying an eye shield to a clients left eye, why does the PN tape the shield from the mid-forehead to the left zygomatic process?

secure the shield with the least amount of facial movement?

There will be pictures of ECG

select the one that looks like a bunch of M's

The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

select the one with hand covering both eyes

A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take?

send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour

During the assessment go a school age child the PN determines that the client is in Ericksons developmental stage of industry vs inferiority. Which behavior did the client demonstrate?

sitting quietly reading a book

The PN is assisting a client to the bathroom after right cataract extraction. The client has an eye shield over the right eye. How should the PN asset the client during ambulation?

stand in front of the client and lead the client forward to the bathroom

A client with lower back pain has been prescribed a transcutaneous electrical nerve stimulator (TENS) unit for pain control. Why would the client be instructed to use this device on the low frequency setting?

stimulate serotonin levels

During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response?

stimulation of uterine contractions

A clients blood pressure is unusually elevated. Which factors would contribute to this clients blood pressure elevation?

stress exercise heart rate body temp

A client has sustained a burn affecting the clients adipose tissue and blood vessels. Which layer of the clients skin has been affected by the burn?

subcutaneous layer

nurse assigns duty to UAP and the UAP just looks at the nurse and walks away what will the nurse do?

submit an incident report relating to the UAP behavior

A nurse is talking loudly in the hall and everybody can hear her personal

suggest nurse go talk in the nurse lounge

When administering iron medicine

take with grapefruit juice

A client with terminal cancer of the liver wants to leave the hospital and spend time at home before dying. Which action would the practical nurse take to help this client?

talk withe the HCP regarding hospice care for the client

Client voiding small amounts every 24 hours

the catherterized volume determines the need to reinsert the indwelling catheter

The mother of a toddler demonstrating a sudden onset of stridor says that the child was playing with an old shirt and suddenly could not breathe very well. What would the PN suspect has occurred with this client?

the child aspirated a button from the shirt

the PN is reviewing new orders for a client and notes that medication doses have been adjusted to lower levels than what is routinely prescribed. Why would this action be taken for the client?

the client has renal failure

an older client with a new onset of confusion tells the family that the nursing staff is "holding her hostage" the family is upset and wants to know what is happening with the client. What would the PN respond to this inquiry?

the client is experiencing confusion

A client who received 10 units of regular insulin is diaphoretic and is shaky. Why would the PN provide the client with graham crackers and milk?

the client is experiencing hypoglycemia

The PN observes a client with major depression giving personal items away to staff and other clients. What does this observation indicate to the PN?

the client is planning to die

A newborn has just been fed and the PN is preparing to change the baby diaper. Why would the PN ensure that a bulb syringe is available at this time?

to aspirate formula in the event the baby vomite when lying flat

Why would the practical nurse remind a postpartum client receiving the rubella vaccine to avoid becoming pregnant for at least 3 months?

to ensure that any fetus is not affected by the live rubella virus

When ambulating a client who has been on bed rest why would the practical nurse first assist the client to a sitting position on the side of the bed?

to help determine the clients response to postural changes

Why would the PN provide a bronchodilator to a client with asthma prior to conducting postural drainage?

to mobilize secretions

The PN is positioning a client recovering from a radical mastectomy. Why will the PN place the client in the semi-fowlers position with the arm of the operative side elevated?

to prevent edema in the arm

Why does the PN administer ophthalmic ointment in the eyes of a newborn?

to prevent gonorrheal or chlamydial ophthalmic infections

Why would the PN encourage the client to use incentive spirometer after surgery?

to prevent onset of repository complications

Why would the PN wash the skin of a client receiving external radiation with water?

to prevent skin irritation and damage

Why does the PN wear a pair of clean gloves when providing care to a client with clostridium difficile ?

to protect the nurse from microorganisms that is within the client

The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of..

total the clients PO intake, fill the water pitchers, empty urinals and catheter bags.

A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report...

urinary output of 20 mL/hr

which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client?

urinary output of 50 mL/hour

Before inserting medication into a clients vagina, what instructions should the pn...

urinate until bladder is empty

A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy?

urine output

The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? photo is of hospital bed and restraint Is on the bed frame in a bow tie

use a full knot to secure the restraint line

In administering nystantin suspension to the gums of an infant with a candida infection, which approach should the PN take?

use a gloved finger to rub the suspension over the infected area

During a health history the PN learns that an older client had the chickenpox virus as a child. Which immunization would be indicated for the client at this time?

vaccination for shingles

The PN provides a prescribed analgesic perianal spray to a postpartum client. For which problem will this nursing action address?

vaginal lacerations

The practical nurse sits at a slight angle to a client who is out of bed in a chair. What will this seating posture promote with the client?

verbalization

The practical nurse needs to provide acetaminophen (Tylenol) to a sleeping client with a gastrostomy tube. The medication is prescribed as tablets, elixir, and suppository. How would the practical nurse provide the medication to the client?

via gastrostomy tube with the elixir

The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond?

washing the hair of a client with a head injury

The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan?

watch the client for abnormal bleeding

A new mother is bottle feeding instead of breastfeeding the PN should instruct the to most effective way to deal with breast engorgement and discomfort is to?

wear a supportive bra at all times

Which action would the practical nurse take to evaluate the hydration status of an infant recovering from abdominal surgery?

weigh diapers and assess urine specific gravity