HESI comprehension practice test
The practical nurse (PN) is talking with an adult male client who says that he is satisfied with how he has lived his life. According to Erikson's staging theory, this client is in which stage? A. Integrity versus despair. B. Intimacy versus isolation. C. Identity versus role confusion. D. Generativity versus stagnation.
A. Integrity versus despair. According to Erikson's Ego theory and developmental model, an older adult who reviews one's life experiences with a sense of satisfaction and is at peace with inevitable death is in the stage of integrity versus despair.
A client with a common cold is seeking treatment at the health clinic. What information should the practical nurse (PN) reinforce to reduce the spread of infection to family members? A. Wash hands after each use of a tissue for nasal drainage. B. Use a dishwasher for all personal dishes and utensils. C. Recommend wearing a mask until all cold symptoms subside. D. Sleep alone in a room and use a humidifier.
A. Wash hands after each use of a tissue for nasal drainage. Handwashing after sneezing, coughing, and blowing the nose is the best defense in reducing the risk of spreading viruses directly or indirectly to others.
Which question should the practical nurse (PN) ask an older male client to best determine the nature of his pain? A. "How bad is it?" B. "Can you describe the pain for me?" C. "Did the pain medication give you relief?" D. "Is this pain the same as you had before?"
B. "Can you describe the pain for me?" Having the client describe the pain in his own words determines the nature and severity of the present sensations.
Which client requires the most immediate assessment by the practical nurse? A. An adolescent with a head laceration oozing serosanguinous drainage. B. A young adult post-appendectomy with an increase in wound drainage. C. A middle-age male with a recent urostomy showing pale yellow drainage. D. An elderly client with a dry dressing over a diabetic ulceration on the great toe.
B. A young adult post-appendectomy with an increase in wound drainage. A client who is post-appendectomy with a sudden increase in wound drainage should be assessed immediately for potential wound dehiscence.
An infant is admitted to the hospital with dehydration and diarrhea. What is the best liquid that the practical nurse (PN) should provide? A. Pedialyte. B. Water. C. Apple juice. D. Ginger ale.
B. Pedialyte. Infants with acute diarrhea and dehydration should be offered oral rehydration solutions (ORS) that do not contribute to diarrhea.
The practical nurse (PN) receives an assignment of four clients. Which action should the PN implement first? A. Administer the morning dose of aspirin 81 mg to a client with a history of angina. B. Take the blood pressures on both arms of a client with moving, "ripping" back pain. C. Notify the healthcare provider that a client with a L3 fracture cannot move either leg. D. Obtain further information from a client with multiple sclerosis who reports ataxia and diplopia.
B. Take the blood pressures on both arms of a client with moving, "ripping" back pain. Moving, "ripping" back pain may be a symptom of an aortic aneurysm dissection, which creates changes in the blood flow volume between the right and left subclavian arteries.
A client with atherosclerosis is trying to stop cigarette smoking and is using a nicotine patch. Which information should the practical nurse (PN) reinforce with this client? A. Abrupt discontinuation of the patch can cause high blood pressure. B. Nausea and vomiting occur with abrupt discontinuation of the patch. C. An increased risk for heart attack occurs with smoking while using the patch. D. Smoking while using the patch increases the risk of a respiratory infection.
C, An increased risk for heart attack occurs with smoking while using the patch. Nicotine in cigarette smoke along with the additive effect of the nicotine patch concomitantly increases vasoconstriction and increases mean arterial pressure, which increases the risk for a myocardial infarction.
Which statement by the mother of a newborn should alert the practical nurse (PN) to offer further information about the care of the umbilical cord? A. "I will use warm water to wash my baby's diaper area with each change." B. "I am going to sponge bathe my baby for the first couple of weeks." C. "I can't wait to bathe my baby in the new baby tub as soon as I get home." D. "I should keep the cord area dry and use an alcohol wipe until the cord falls off.
C. "I can't wait to bathe my baby in the new baby tub as soon as I get home." The infant should not be submerged in a tub bath until the umbilical cord dries and falls off.
Which nursing action for a client who was bitten by a black widow spider is within the scope of practice of the practical nurse (PN)? A. Provide discharge wound care instructions. B. Assess for respiratory compromise. C. Administer intramuscular (IM) tetanus toxoid. D. Determine degree of tissue destruction.
C. Administer intramuscular (IM) tetanus toxoid. The administration of IM injections is within the scope of practice for the PN.
Which anticholinergic agent is used for bradydysrhythmias? A. Atropine. B. Hyoscyamine (Levsin). C. Dicyclomine (Bentyl). D. Glycopyrrolate (Robinul).
C. Atropine. Atropine is an anticholinergic drug that increases the heart rate and is used in bradydysrhythmias.
A client with acute pancreatitis has a low serum calcium level. The practical nurse (PN) observes that the lips, nose, and side of the face contract after the client's face is cleansed with a cloth. Which documentation describes these findings? A. Bell's palsy noted. B. Tic douloureux noted. C. Chvostek's sign noted. D. Trousseau's sign noted.
C. Chvostek's sign noted. Chvostek's sign indicating low serum calcium is manifested by spasms of the muscles innervated by the facial nerve, which is elicited by tapping the client's face lightly below the temple.
The practical nurse (PN) is assessing a child who has a cast on the right lower leg. Which finding should the PN report to the charge nurse? A. Requests to wear socks over right foot. B. Complaints of feeling hot. C. An increased respiration rate. D. A foul odor from the cast's edge.
D. A foul odor from the cast's edge. Once a cast dries, warmth felt on the cast surface or foul smelling areas of the cast may indicate infection and should be reported.
The PN is caring for a client with chronic kidney disease (CKD). What info should the PN reinforce about medication management? A. Oral iron supplements reverse chronic anemia in CKD. B. Calcium supplements are needed to maintain serum levels. C. Nonsteroidal antiinflammatories are safe to use for pain. D. Antihypertensive drugs should always be used as directed.
D. Antihypertensive drugs should always be used as directed. Blood pressure control is essential for a client with CKD because hypertension and cardiovascular disease occur with the progression of CKD.
A terminally ill male client and his family are requesting hospice care after discharge and ask the PN to explain what kind of care they should expect. The PN should indicate that hospice philosophy focuses on what aspect of health care? A. Offers ways to postpone the death experience at home. B. Facilitates assisted suicide with the client's consent. C. Provides training for family members to care for the client. D. Enhances symptom management to improve end-of-life quality.
D. Enhances symptom management to improve end-of-life quality. Symptom management, such as pain control and comfort measures, is part of the philosophy of hospice care.
The practical nurse (PN) is monitoring a client who is admitted in active labor. After reviewing the nursing admission assessment, the PN determines the client's membranes have been ruptured for 36 hours. The PN should monitor the client for which risk factor? A. Excessive bleeding. B. Precipitous labor. C. Supine hypotension. D. Intrauterine infection.
D. Intrauterine infection. When a client is in active labor with spontaneous rupture of membranes (SROM) longer than 24 hours, microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and placentitis.
The practical nurse (PN) is caring for a client with dementia. Which finding should the PN report to the charge nurse that indicates the client's condition is getting worse? A. Spontaneous emotional responses. B. Fewer episodes of incontinence. C. Decreased agitation. D. Loss of contact with environment.
D. Loss of contact with environment. Dementia is a client's loss of cognitive abilities, including judgment, abstract thought, memory, language, and the ability to think and understand the environment.
A client with hypothyroidism receives a prescription for thyroid hormone replacement. Which sign(s) of overdose should practical nurse (PN) reinforce with the client? (Select all that apply.) A. Weight gain. B. Ataxia. C. Bradycardia. D. Nervousness. E. Irritability. F. Difficulty sleeping.
D. Nervousness. E. Irritability. F. Difficulty sleeping. An overdose of thyroid hormone replacement mimics the signs and symptoms of hyperthyroidism, which include nervousness, irritability, and insomnia.
Which finding should the PN report to the healthcare provider that indicates a client with cirrhosis is progressing to hepatic encephalopathy (hepatic coma)? A. 2+ pitting edema up to lower thighs B. Serum clotting results three times above normal C. Spider nevi (telangiectasias) D. Serum ammonia levels twice the normal value
D. 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.
The practical nurse (PN) is caring for a client in hospice who is comatose and needs vigorous suctioning. The PN is conflicted about implementing the needed care. What ethical action should the PN do first? A. Ask for a different client care assignment. B. Refer to the client's living will documentation. C. Review the nursing code of ethics for guidance. D. Speak with the unit supervisor about the problem.
D. Speak with the unit supervisor about the problem. The first step in processing an ethical decision is clarification of one's personal values by discussing the issue with other nurses, the unit supervisor, or the ethics committee.
The PN is observing a newborn's breathing pattern. Which breathing pattern should the PN document as normal for this full-term newborn? A. Deep breaths with a normal regular rhythm. B. Thoracic breathing with nasal labial flaring. C. Diaphragmatic breathing with chest retraction. D. Synchronal chest and abdominal movements.
D. Synchronal chest and abdominal movements. Abdominal movements synchronous with chest movements are normal in a healthy full-term infant.
The PN is administering a dissolved medication via NGT. After putting on gloves and attaching the irrigation syringe to the NGT, in which order should the PN implement the actions? (first on top to last on bottom) A.Release tubing slowly to allow solution to flow B. Observe client for indications of intolerance during installation C. Add medication solution after pinching tubing D. Pinch the tubing to pour 15-30 mL of tap water in the syringe barrel
1. Pinch the tubing to pour 15 to 30 ml of tap water in the syringe barrel. 2. Release the tubing slowly to allow the solution to flow. 3. Observe the client for indications of intolerance during instillation. 4. Add the medication solution after pinching the tubing.
The PN is planning to attend an educational offering for CEUs or contact hours. In order to qualify for CEUs, the PN must recognize that the offering should include which essential element? A. Has at least one speaker with a masters degree B. Demonstrate a need by assessment survey C. Has measurable outcome objectives D. Includes a question an answer period at the end
C. Has measurable outcome objectives
An unlicensed assistive personnel (UAP) reports a blood pressure (BP) reading of 148/88 for a 10 year-old child who is above the 95th percentile on the growth chart. What intervention should the practical nurse (PN) implement? A. Check the size of the blood pressure cuff used. B. Instruct the UAP to repeat the BP measurement. C. Ask about the child's activity prior to the measurement. D. Review the child's history for evidence of renal disease.
A. Check the size of the blood pressure cuff used. The size of a BP cuff should be checked because a cuff that is too small for a child above the 95th percentile is mostly likely to result in a falsely elevated reading.
An older client is being discharged from the hospital to return to the assisted living community after undergoing a right hip replacement. The client is using a four-point walker. When planning the client's discharge, which member of the healthcare team is most important for the practical nurse to coordinate continued care for the client? A. Case manager B. Physical therapist C. Occupational therapist D. Social worker
B. Physical therapist
The PN is providing wound care for a newly admitted client with partial to full-thickness burns of the torso. Place the steps in order of first to last implementation? (first on top to last on bottom) A. Don gown, mask, and gloves B. Apply topical silver sulfadiazine C. Maintain room temp above 76 F D. Administer prescribed opioid analgesic E. Cleanse wound with sterile normal saline
1. Maintain room temp above 76F 2. Administer prescribed opioid analgesic 3. Don gown, mask, and gloves 4. Cleanse wound with sterile normal saline 5. Apply topical silver sulfadiazine (Silvadene)
An older Hispanic male is admitted with a nutritional deficiency and is prescribed a regular diet. The client frequently says that he dislikes the hospital foods and wants to eat food brought in by his family. Which response is best for the PN to provide? A. Warn the family about the need for adequate food temperature control. B. Request the dietitian review the nutritional content of family foods. C. Explain to the family that the hospital is providing a balanced diet. D. Thank the family for bringing the foods that the client likes to eat.
B. Request the dietitian review the nutritional content of family foods. Culture affects acceptability of food, as well as patterns of food intake. Since nutritional requirements depend on many factors, adequacy of the diet brought by the family should be determined.
The practical nurse (PN) is working in the eye clinic where several clients are waiting to be seen. Which client should the PN place in the ophthalmologist's examination room first? A. An adolescent with photosensitivity due to something in the right eye. B. An older client with unilateral blurry vision over the past year. C. An adult male with a sudden onset of a curtain across field of vision today. D. A female client with erythremic eyelids and scales on eyelashes.
C. An adult male with a sudden onset of a curtain across field of vision today. A sudden onset of loss of vision as if a curtain fell across the visual field is a classic symptom of retinal detachment
A mother calls the clinic to find out what she can do because a note from school has been sent to her about a reported case of head lice in her child's class. What information should the practical nurse (PN) provide? A. Wash your child's hair with permethrin 1% (Nix). B. Cut your child's hair to an extremely short length. C. Keep the child home from school for a week. D. Tell the child to not share personal grooming items.
D. Tell the child to not share personal grooming items. Primary prevention should be implemented and includes informing the parent about the mode of transmission for head lice. The mother should instruct her child to not share personal grooming items because direct contact and shared objects play a role in the mode of transmission.
The practical nurse (PN) is planning care for a client who is admitted with a Braden scale score of 2 in each of the six subcategories. Toward which goal in the client's care should the PN focus nursing interventions? A. Prevention of pressure ulcers. B. Improved hygienic measures. C. Temperature within normal limits. D. Absence of signs of infection.
A. Prevention of pressure ulcers. The Braden scale measures degrees of sensory perception, moisture, activity, mobility, nutrition, friction, and shear that indicate a client's risk for skin breakdown.
Which interventions should the practical nurse (PN) implement in the postoperative period for a client who had surgery for cancer of the oral cavity? (Select all that apply.) A. Provide meticulous oral hygiene. B. Advise the client to avoid straining on stool. C. Obtain daily weights to determine need for NGT feedings. D. Observe for temporary or permanent loss of taste. E. Monitor for gastric indigestion.
A. Provide meticulous oral hygiene. C. Obtain daily weights to determine need for NGT feedings. D. Observe for temporary or permanent loss of taste.
Which client information determines the best assignment for the practical nurse (PN)? A. Client who takes spironolactone has a serum potassium of 5.9 mEq/L. B. Client with dependent edema is scheduled for discharge to home care. C. Client who is admitted in the morning is having severe vomiting and diarrhea. D. Client with a non-tunneled central catheter has severe fluid volume deficiency.
B. Client with dependent edema is scheduled for discharge to home care.
Which incident should the PN identify as a client confidentiality violation under HIPPA regulations? A. A nurse conveys client status info to an inquiring friend on the phone without the client's permission B. The unit secretary faxes a client's old records from the office to the emergency center without written consent C. A client overhears a verbal prescription in the next room during a cardiac arrest of another client D. A client discusses his personal history of kidney stones with another client in the unit's lounge area
A. A nurse conveys client status info to an inquiring friend on the phone without the client's permission
The practical nurse (PN) receives report for four clients. While providing care, which client should the PN observe closely for hypernatremia? A. An older client with quadriplegia who is disoriented today. B. An older client with influenza who vomited once today. C. A client with diabetic ketoacidosis (DKA) who is sighing with rapid respirations. D. A client who is receiving D5W in 0.45 NS one liter q12 hours postoperatively.
A. An older client with quadriplegia who is disoriented today. An older client with quadriplegia has a limited ability to respond to stimuli, such as a decreased sense of thirst which is an initial response to hypernatremia that manifests with mental confusion, is an early sign of hypernatremia.
The practical nurse (PN) is reviewing dietary recommendations for a client who is newly diagnosed as hypertensive. Which information is most important for the practical nurse (PN) to reinforce? A. Check sodium content on all canned foods. B. Recommend use of alcohol in moderation. C. Use salt substitute as desired to enhance flavor. D. Reduce fats by substituting fish for red meat.
A. Check sodium content on all canned foods. Canned foods contain high levels of sodium, so the client should review the salt content on labels of canned products and limit this intake.
Which finding in a newborn is most important for the practical nurse (PN) to report? A. Clinical jaundice evident on the forehead within 24 hours of birth. B. Icterus color of blanched skin on the thorax at day 3 after birth. C. Serum bilirubin concentrations less than 2 mg/dl in cord blood. D. Bilirubin level of 4 mg/dl using a transcutaneous bilirubinometry.
A. Clinical jaundice evident on the forehead within 24 hours of birth. Jaundice is clinically visible when bilirubin levels reach 5 to 7 mg/dl and appears in a cephalocaudal manner, first noticed in the head, and then progresses gradually to the thorax, abdomen, and extremities. Clinical jaundice that is evident within 24 hours of birth warrants immediate attention and is pathological. Although additional assessments of physiological jaundice should be made, jaundice in the first 24 hours is life threatening and requires immediate intervention.
The unlicensed assistive personnel (UAP) asks the practical nurse (PN) how to position a client for tube feedings? A. Elevate the head of the bed. B. Use a Sims' position. C. Place in a left lateral position. D. Allow a position of comfort.
A. Elevate the head of the bed. The head should be elevated 45 degrees before and one hour after feeding to reduce the possibility of aspiration.
The practical nurse (PN) is caring for an older client with an infection. Which finding should the PN anticipate as a delayed response in this client? A. Fever. B. Fatigue. C. Malaise. D. Confusion.
A. Fever. An early systemic immune response is fever, but older clients are at risk for an impaired immune response related to chronic illness or polypharmacy, such as antiinflammatory steroids.
A male client diagnosed with schizophrenia reveals to the PN that voices have told him he is in danger. He believes he is safe only if he stays in his room and wears the same clothes. He goes on, "They're so loud they frighten me. Don't you hear them?" What is the best response for the PN to provide? A. I know these voices are very real to you, but I don't hear them. B. Tell me more about the voices and if they are men or women. C. You're safe in the hospital and nothing will happen to you. D. You should get out of your room so you don't hear the voices.
A. I know these voices are very real to you, but I don't hear them. When asked to validate the hallucination, the PN should respond with the reality that the nurse is not experiencing the same stimuli as the client.
Which client should the practical nurse (PN) identify as the priority for a focused assessment? A. Older female with pneumonia who is newly confused to person. B. Adult male who is receiving an IV infusion reports his arm is cold. C. Older male with serum potassium of 3.2 mEq/L on first postoperative day. D. Adult female with white cell count of 9,900 mm3 who has pyelonephritis.
A. Older female with pneumonia who is newly confused to person. A new onset of change in a client's mental status is often related to poor perfusion and cerebral oxygenation and should be assessed first.
A 34-year-old male client who is admitted to the mental health unit for paranoia is responding to antipsychotic medications. After the healthcare team decides to discharge the client, he tells the practical nurse (PN) that his wife is unfaithful and he plans to get her for this. How should the PN respond? A. Report to the team that the client's wife should be informed. B. Ask the client if he will comply with the mandatory day hospital visits. C. Tell the client to discuss his medication dose with his healthcare provider. D. Explain the consequences if he carries out his threats to his wife.
A. Report to the team that the client's wife should be informed. Mental healthcare member has the responsibility of Duty to Warn and report any intended, identified victim of possible future harm by a client.
The PN is caring for a client who is receiving a therapeutic dose of warfarin (Coumadin). The client asks the PN to explain the effect of eating green leafy vegetables. What info should the PN provide? A. The high content of vitamin K in green leafy vegetables decreases Coumadin's action. B. Green vegetables are high in fiber and cellulose that decrease the absorption of Coumadin. C. These foods have a natural anticoagulant effect that potentiates the effect of Coumadin. D. Dietary intake of green leafy vegetables alters the bowel bacteria's production of vitamin K.
A. The high content of vitamin K in green leafy vegetables decreases Coumadin's action. Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin K in the production of prothrombin, which is a component of the blood clotting cascade. Green leafy vegetables are high in vitamin K, which counteracts the anticoagulant effect of Coumadin.
Based on The Joint Commission (TJC) standards for pain assessment and treatment, which action is most important for the practical nurse (PN) to implement when assessing a client? A. Use a pain scale to assess all clients for pain when obtaining vital signs. B. Collect objective information about pain to provide the best prescribed treatment. C. Prioritize pain assessment for surgical clients before clients with chronic illness. D. Give prescribed medications to all clients with outward expressions of pain.
A. Use a pain scale to assess all clients for pain when obtaining vital signs. The priority action, consistent with TJC pain standards, includes assessing all clients for pain, the fifth vital sign, which is best determined with a pain scale.
A client with deep partial-thickness and full-thickness burns of the face and chest is receiving wound care using the open method. The plan of care includes the Nsg Dx, "Risk for infection R/T impaired tissue integrity." Based on the expected outcome, "Client remains free of infections," which nursing interventions should the PN implement? A. Wear gown, cap, mask, and gloves during direct client care. B. Restrict visitors in order to prevent wound contamination. C. Use sterile water for debridement in the hydrotherapy tank. D. Apply sterile dressings after debridement of burn wounds.
A. Wear gown, cap, mask, and gloves during direct client care. No dressing is used for burn wound care using the open method. The burn area is exposed and an aseptic environment is needed to prevent contamination and infection. Protective isolation precautions should be implemented during direct client care and wound care, which should include wearing gown, cap, mask, and gloves.
The PN is reinforcing the discharge instructions for a female client with cystitis. Which statement indicates to the PN that the client understands measures to prevent urinary tract infections (UTI)? A. "I will limit my fluid intake to 1000 ml/day to prevent symptoms of frequency and urgency." B. "Every 2 to 3 hours during waking hours, I will drink a glass of water and empty my bladder." C. "I will use an antiseptic vaginal deodorant spray to reduce perineal bacterial growth." D. After each bowel movement, I will wash my perineal area with soap and water.
B. "Every 2 to 3 hours during waking hours, I will drink a glass of water and empty my bladder." Measures to reduce the risk of UTI include liberal fluid intake, frequent bladder emptying, and hygienic measures to prevent ascending bacterial contamination of the bladder. The client's statement that best indicates understanding includes maintaining a regular and frequent fluid intake and urination every 2 to 3 hours during the day.
What action should the practical nurse (PN) implement first for a client with a head injury and clear nasal drainage? A. Obtain a specimen of the fluid for culture and sensitivity. B. Check the nasal drainage with a glucose test strip. C. Assess the client's temperature every 2 to 4 hours. D. Inspect the nares bilaterally for signs of inflammation.
B. Check the nasal drainage with a glucose test strip. If the client is exhibiting clear nasal drainage after a head injury, the first action is to determine if the fluid is cerebrospinal fluid (CSF). Glucose is present in CSF.
Based on these clients' laboratory results, which client should be assigned to the practical nurse (PN)? A. Client with a serum sodium of 129 mEq/L. B. Client with a serum calcium of 9.5 mg/dl. C. Client with a serum potassium of 6.0 mEq/L. D. Client with a serum phosphorus of 2.7 mEq/L.
B. Client with a serum calcium of 9.5 mg/dl. Non-complex client acuity determines client care assignments that should be aligned with the PN's scope of practice.
What action should the PN implement to facilitate speech for a client who has a fenestrated tracheostomy tube? A. Show the client how to use a tracheostomy plug. B. Determine the client's ability to swallow. C. Remove the inner cannula. D. Give oxygen at 6 L/minute via tracheostomy collar.
B. Determine the client's ability to swallow. A fenestrated tracheostomy has an opening or hole on the posterior aspect of the outer cannula that allows airflow over the vocal cords and speech in a client who is spontaneously breathing. It does not have a cuff, so the client's risk for aspiration should be determined.
Which site should the practical nurse (PN) avoid when administering IM immunizations to toddlers? A. Ventrogluteal. B. Dorsogluteal. C. Rectus femoris. D. Vastus lateralis.
B. Dorsogluteal. The IM dorsogluteal site should be avoided in infants, toddlers, and smaller preschoolers due to the risk of damaging the sciatic nerve.
At the scene of a motor vehicle collision, the practical nurse (PN) stops to render assistance to a victim who has bleeding injuries of the face and neck. Which action should the PN implement after establishing that the victim is unresponsive? A. Deliver two mouth-to-mouth breaths. B. Immobilize the head and neck. C. Open the airway using jaw thrust method. D. Clear the airway using a finger sweep.Open the airway using jaw thrust method.
B. Immobilize the head and neck. Cervical spine trauma should be suspected in any client with significant upper torso, face, head, or neck trauma, so cervical immobilization should be applied prior to opening the airway using the jaw thrust, instead of the head tilt method.
A client is wearing a continuous 24-hour Holter monitor for elevation of heart rhythm disturbances. What info should the PN reinforce with this client? A. Remove the electrodes to shower or bathe B. Keep a diary of activities as long as the monitor is worn. C. Exercise as much as possible while the monitor is in place. D. Call the assigned number if an episode of irregular heartbeats occurs.
B. Keep a diary of activities as long as the monitor is worn. Nursing care for a client with a Holter monitor includes preparation of the skin, placement of the electrodes and leads, and activities of daily living, so the client should be informed of the importance of keeping an accurate record of activities and symptoms
What action should the practical nurse (PN) implement when administering ear drops to a 2-year-old child? A. Give the ear drops upon removal from the refrigerator. B. Pull the pinna back and down to instill the drops. C. Massage the helix after medication administration. D. Insert a sterile cotton ball into the ear canal.
B. Pull the pinna back and down to instill the drops. When instilling ear drops to a child under 3 years of age, the ear canal is straightened by pulling the pinna back and down.
Which finding should the practical nurse report that is the first indication a child with a tracheostomy is experiencing respiratory distress? A. Cyanosis. B. Restlessness. C. Sternal retractions. D. Crowing respirations.
B. Restlessness. Unless respiratory arrest occurs suddenly, signs of hypoxemia and hypercapnia are usually subtle and become more obvious as respiratory distress progresses. A child with a tracheostomy may develop airway obstruction from increased airway secretions, which decreases cerebral oxygenation, initially causing restlessness.
The practical nurse (PN) is reviewing the medication dosage instructions with a parent whose child is taking levothyroxine (Synthroid). What statement reveals that the parent understands the correct procedure? A. "I don't give the medication on the weekends." B. "I give the medication at 8:00 am every day." C. "I am using a different brand now because it costs less money." D. "I stopped giving the medication because my daughter was losing her hair."
C. "I give the medication at 8:00 am every day." A child with hypothyroidism should receive Synthroid every day at the same time.
Which client is the best assignment for the practical nurse (PN)? A. A client with renal failure and excessive peripheral edema. B. A client with fluid overload who needs intravenous (IV) medication. C. An older adult client with dehydration who needs assistance with feeding. D. An older adult client with fluid volume deficit and a history of laxative abuse.
C. An older adult client with dehydration who needs assistance with feeding.
The nursing staff team includes an RN, PN, and UAP. Which task should be assigned to the PN? A. Stocking linen closet with additional sheets B. Assigning lunch times for each team member C. Changing decubiti dressing for immobile client D. Administering blood to a client with an active GI bleed
C. Changing decubiti dressing for immobile client
The PN performs a random blood glucose test for a client with a history of hypoglycemia and complaints of dizziness. After test completion, which action should the PN perform first? A. Remove gloves and wash hands. B. Document results and actions in the medical record. C. Dispose of lancet and test strip in proper receptacle. D. Discuss the test results with the client.
C. Dispose of lancet and test strip in proper receptacle. Disposal of the lancet and test strip prevents the transmission of bloodborne pathogens and is the priority.
A client with advanced cirrhosis is prescribed lactulose (Cephulac) 30 ml QID. The client complains that the medicine is causing diarrhea. Which therapeutic response of the medication should the PN provide the client? A. Promotes fluid loss. B. Prevents constipation. C. Excretes ammonia to improve cerebral function. D. Reduces the risk for gastrointestinal bleeding.
C. Excretes ammonia to improve cerebral function. To treat portal-systemic encephalopathy, lactulose causes the movement of serum ammonia, which accumulates due to hepatic dysfunction in cirrhosis, into the gut and results in diarrhea due to the osmotic movement of water.
An older male client with chronic pain due to degenerative joint disease frequently cries at night because he cannot go to sleep. Which additional finding should the practical nurse (PN) mostly likely observe in this client? A. Changes in vital signs during episodes of pain. B. Ability to localize painful and nonpainful areas. C. Fatigue, depression, helplessness, and anger. D. Pain relief when analgesics are staggered.
C. Fatigue, depression, helplessness, and anger. Chronic pain affects an individual's ability to cope, rest, or function independently, and often manifests in behavioral changes.
Which action should the practical nurse (PN) implement to provide a sense of control to a toddler who is hospitalized? A. Put a cover over the child's crib. B. Ask parents to stay with the child. C. Assign the same nurses to care for the child. D. Follow the child's usual routines for feeding and bedtime.
C. Follow the child's usual routines for feeding and bedtime. Routines are important to toddlers and give the child a sense of control, so following the child's usual routines during hospitalization should be implemented as much as possible.
The practical nurse (PN) is reviewing the medical record for an infant with hydrocephalus. Which focused assessment finding should the PN document? A. Constricted pupils. B. A sunken anterior fontanel. C. Increased head circumference. D. Decreased luminosity of the head.
C. Increased head circumference. A classic sign of hydrocephalus is an increase in head circumference due to the increase in cerebrospinal fluid (CSF), which should be identified during a focused assessment and documented in the medical record.
Which factor should the practical nurse (PN) consider prior to providing morning hygiene care to a male client who is of Middle-Eastern descent? A. Skin color. B. Economic status. C. Personal preferences. D. Sociocultural background.
C. Personal preferences. Hygiene is considered an invasion of personal space, and clients vary in their perceptions of how and who may assist in their care.
The practical nurse (PN) is caring for a 2½-year-old child with Wilms' tumor. Which intervention is most important for the PN to implement? A. Check skin turgor for elasticity and hydration. B. Place a sign in the room stating no abdominal palpation. C. Auscultate all lung fields for abnormal breath sounds. D. Distract the child with a toy during daily assessments.
C. Place a sign in the room stating no abdominal palpation. Abdominal palpation in a child with Wilms' tumor can cause the cancer to spread throughout the peritoneum, so should be prohibited.
After undergoing exploratory laparotomy and bowel resection, a client with an NG tube to suction complains of nausea and stomach distention. The PN irrigates the tube, but the irrigating fluid does not return. What action should the PN implement? A. Notify the healthcare provider. B. Auscultate for bowel sounds. C. Reposition the tube and check for placement. D. Remove the tube and replace it with a new one.
C. Reposition the tube and check for placement. Patency and position of a NGT are checked frequently to evaluate for dislodgement or NGT obstruction with mucous, sediment, or blood clots. The placement should be verified and repositioned in the stomach to obtain a return of the normal saline used to irrigate the NGT.
Which client should the practical nurse implement the Glasgow Coma Scale (GCS) assessment? A. A client with alcohol intoxication who mumbles in response to questions. B. A client admitted with diabetic ketoacidosis and a blood glucose level of 400 mg/dl. C. A client admitted with a seizure disorder who is started on a different anticonvulsant. D. A client with a closed head injury who refuses to follow verbal commands.
D. A client with a closed head injury who refuses to follow verbal commands. GCS evaluates the degree of consciousness impairment using the parameters of eye opening, verbal response, and motor response in clients with head injuries.
Which intervention is most important for the practical nurse to implement when suctioning the nasopharyngeal airways for a child after cardiac surgery? A. Perform oropharyngeal suctioning PRN. B. Suction for no longer than 5 seconds at a time. C. Assess for symptoms of respiratory distress during suctioning. D. Administer supplemental oxygen before and after suctioning.
D. Administer supplemental oxygen before and after suctioning. Hypoxia increases the cardiac workload after cardiac surgery, so supplemental oxygen should be administered with a manual resuscitation bag before and after suctioning to prevent hypoxia.
The practical nurse (PN) is caring for an older female client who has left-sided weakness after a cerebrovascular accident. The client states that she wants to do her own sponge bath. Which action should the PN implement? A. Explain that the nurse should provide the bath to prevent extension of the CVA. B. Provide the client with bath water and clean the area after self care is completed. C. Tell her to rest because the nurse's assistance will conserve her energy. D. Encourage her to do what she can and assist her when she needs help.
D. Encourage her to do what she can and assist her when she needs help. Encouraging the client to be as independent as possible, with assistance as needed, helps the client regain a sense of independence and prevents problems associated with inactivity.
Which action should the practical nurse implement to ensure that a hospitalized toddler takes a prescribed dose of an oral medication? A. Tell the child that the medication is candy and tastes good. B. Reassure the child that it will make the child feel better right away. C. Explain to the child firmly that the drug is important to take as soon as possible. D. Convey to the child in simple terms what the medication is for and how it is given.
D. Convey to the child in simple terms what the medication is for and how it is given. Explaining to the toddler what the drug is for and how it is given should be provided using simple language and short sentences.
Which information related to a client's history of benign prostatic hypertrophy (BPH) should the practical nurse (PN) report to the healthcare provider? A. Change in bowel movements. B. Persistent lower back pain. C. White penile discharge. D. Difficulty with urination.
D. Difficulty with urination. The prostate gland lies below the bladder neck and surrounds the urethra. An increase in the size of the prostate gland caused by BPH compresses the urethra, resulting in difficulty initiating the urinary stream.
The practical nurse (PN) is assisting an adult female client with perineal care. Which position should the PN assist the client to take? A. Prone. B. Supine. C. Side-lying D. Dorsal recumbent.
D. Dorsal recumbent. To perform female perineal care, a client should be assisted to the dorsal recumbent position, which provides visualization, comfort, and medical aseptic technique.
A couple who are both carriers of the sickle cell trait ask the practical nurse (PN) to clarify their children's risk of inheriting this disease? A. Every fourth child will manifest the disease. B. All of their children will be carriers of sickle cell trait. C. The risk levels for their children cannot be determined. D. Each child has a 50% chance of being a carrier.
D. Each child has a 50% chance of being a carrier. Both parents are carriers, so there is a 25% chance that each offspring will inherit the defective gene from both parents and manifest the disease, a 50% risk of being a carrier, and 25% chance of inheriting the normal genes.
The caregiver of an 88-year-old client tells the PN that the client takes frequent naps during the day and awakens frequently during the night. Which information should the PN provide? A. The client should be given a hypnotic to ensure an adequate sleep pattern through the night. B. To prevent fatigue, an older client should obtain at least 10 hours of sleep in 24 hours. C. An older client should nap less during the day to ensure a longer sleep pattern at night. D. It is normal for an aging client to awaken more often during the night and nap during the day.
D. It is normal for an aging client to awaken more often during the night and nap during the day. Sleep habits are very individualized, but an older client normally sleeps less at night with more naps being taken during the day, so the caregiver should be reassured that this is an expected, normal sleep pattern for the client.
What therapeutic response should the PN monitor for in a client who is taking medications for tuberculosis? A. Cessation of a chronic cough. B. Tolerance to medication regime. C. Negative purified protein derivative (PPD) skin test. D. Negative sputum cultures and chest xray.
D. Negative sputum cultures and chest xray. Therapeutic effectiveness of antitubercular drugs is supported by clinical findings indicating negative sputum cultures for the acid fast bacilli and improved chest radiographs.
An older client is admitted with anemia after an episode of acute blood loss. Which assessment finding should the practical nurse (PN) report? A. Refuses green, leafy vegetables. B. Output 150 ml dark amber urine. C. Red and tender joints in hands. D. Tarry stool last bowel movement.
D. Tarry stool last bowel movement. Anemia due to an acute episode of blood loss, such as gastrointestinal bleeding, can cause tarry stools and should be reported.
The PN is reviewing the use of a new digital thermometer with a group of unlicensed assistive personnel (UAP). Which indicator should the PN use to best evaluate that the UAPs understand the use of the thermometer? A. UAPs who scored 100% on written tests are competant B. UAPs have no questions and indicate understanding C. Randomly-chosen UAPs state step-by-step directions D. UAPs are repeatedly observed using equipment correctly
D. UAPs are repeatedly observed using equipment correctly
The PN is caring for a child who is receiving chemotherapy for leukemia. The child's granulocyte count is 250/mm3 and the platelet count is 20,000/mm3. Which intervention should the PN implement when performing oral hygiene? A. Use a toothbrush and floss once a day. B. Rinse the mouth out with lukewarm water. C. Clean the teeth with a toothbrush twice daily. D. Wipe teeth with moistened gauze sponges.
D. Wipe teeth with moistened gauze sponges. Based on the child's laboratory results, the child is at risk for bleeding and infection.
A female client receives a new prescription for an oral contraceptive. Which information should the PN reinforce with the client? A. Sit up for 30 minutes after ingestion. B. Drink a glass of water with the medication. C. Take the pill at the same time every day. D. Avoid taking the medicine with grapefruit juice.
C. Take the pill at the same time every day. An oral contraceptive should be taken at the same time every day to maintain hormone levels and provide the best effectiveness.
Rank the sequence of physiological changes that a newborn must initiate and adapt to extrauterine life after Cesarean delivery? (Most critical from top to bottom) A. Response of immune defense system B. initiation of respirations C. Closure of fetal circulatory shunts D. Maintenance of temperature
1. Initiation of respirations. 2. Maintenance of body temperature. 3. Closure of fetal circulatory shunts. 4. Response of immune defense system.
An older male client who takes several medications comes to the clinic complaining of loss of appetite and fatigue. He tells the practical nurse (PN), "Things look blurred, yellow, and sometimes have rings around them." Which medication should be withheld until further assessment of laboratory tests is obtained? A. Digoxin (Lanoxin). B. Ibuprofen (Motrin). C. Potassium (K-Dur). D. Hydralazine HCl (Apresoline).
A. Digoxin (Lanoxin). Blurred, yellowed vision with halos, anorexia, and fatigue are common findings of digoxin toxicity.
A client who delivered a 7 pound 8 ounce infant 3 hours ago has a soft, boggy uterus located above the umbilicus. What action should the practical nurse implement next? A. Perform fundal massage. B. Notify the charge nurse. C. Obtain a blood pressure. D. Initiate perineal pad count.
A. Perform fundal massage. A soft, boggy uterus places the client at increased risk for postpartum hemorrhage, so the PN should perform fundal massage to contract the uterus.
Which nursing action for a client who had a near-drowning experience is within the scope of the practical nurse (PN)? A. Collect arterial blood specimens and report ABG results to the healthcare provider. B. Maintain cervical spine precautions during client transfers to a stretcher. C. Coordinate transferring the client to another hospital using flight team support. D. Assess lung sounds and neurological status for clarification with the family.
B. Maintain cervical spine precautions during client transfers to a stretcher. Stabilizing the client's spine during transfer to a stretcher is a basic nursing skill that is within the scope of practice for a PN.
A male client scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the PN if he will ever be able to speak. Which response is bets for the PN to provide? A. Breathing occurs through a permanent neck opening which prevents normal speech. B. Permanent removal of the voice box requires rehabilitation for esophageal speech. C. Due to removal of the vocal cords, communication requires the use of sign language. D. Once the breathing hole in the neck heals, the ability to speak requires a device.
B. Permanent removal of the voice box requires rehabilitation for esophageal speech. A total laryngectomy includes removal of the larynx and pre-epiglottis region resulting in a permanent tracheostomy and loss of normal speech abilities. Rehab is required to learn to speak using a prosthesis, esophageal speech, or an electrolarynx.
A client is 24-hours post-endoscopic retrograde cholangiopancreatography (ERCP) for cholelithiasis. Which finding should the PN report to healthcare provider? A. Serum bilirubin elevation four times above normal value B. Serum amylase elevation three times above normal value C. Steatorrhea D. Jaundiced sclera
B. Serum amylase elevation three times above normal value ERCP can cause a gallstone to move into the common bile duct, obstructing flow into duodenum and cause pancreatitis, which is evidences by increase in serum amylase.
A female client with terminal cancer is tearful and is becoming increasingly withdrawn from her family and the nursing staff. She refuses medications, treatments, food, and frequently says, "Why is God doing this to me?" Which intervention should the practical nurse implement? A. Monitor for an increased suicide risk. B. Implement measures to reduce her pain level. C. Contact her religious advisor to help her face death. D.Initiate discussions about her wishes for end-of-life care.
C. Contact her religious advisor to help her face death. The client's religious advisor should be contacted to assist the client cope with her spiritual distress regarding death. Although discussions about end-of-life care should be initiated, the client's religious advisor, family, or healthcare provider should assist her in coordinating her wishes.
The practical nurse (PN) is caring for a school-aged child with Reye's syndrome. What action is most important for the PN to implement? A. Observe the skin for petechiae. B. Reposition every 2 hours. C. Monitor intake and output. D. Perform range-of-motion exercises.
C. Monitor intake and output. Reye's syndrome is characterized by a nonspecific encephalopathy with fatty degeneration of the liver and is triggered by a virus, particularly influenza or varicella, in association with the concurrent use of salicylates. Fluid management focused on monitoring and treating increased intracranial pressure (ICP) is crucial, so monitoring intake and output (C) is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema.
Which action should the practical nurse (PN) implement when giving medications to a 3-year-old child? A. Instruct the child of the urgency to take the medication right away. B. Offer the child the option to take the medication orally or by injection. C. Compare the child's actions to another child who readily takes medication. D. Allow the child to choose fruit punch or apple juice with oral medications.
D. Allow the child to choose fruit punch or apple juice with oral medications. Realistic choices allow the child to exert control when medications are required during hospitalization.
A new father asks the practical nurse (PN) the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide? A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visual deficits. B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina. C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyes in the newborn. D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection.
D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection. Because of the risk of blindness from an ophthalmic infection acquired during vaginal birth, if mother is infected with a gonorrheal or chlamydial organism.
What action should the PN take when implementing daily focused assessments for this assigned group of 4 clients? A. Apply BP cuff on client's forearm when upper arm can't be used B. Measure a child's length from feet to shoulders using a Breslow tape C. Palpate the abdomen prior to auscultation for presence of bowel sounds D. Dispose of gastric residual volume after aspirating client's NG tube
A. Apply BP cuff on client's forearm when upper arm can't be used Forearm and calf can be used to rad BP if upper arm can't be used.
When taking the blood pressure of a client, how should the practical nurse (PN) position the client's upper arm? A. At the level of the heart. B. Below the level of the heart. C. Above the level of the heart. D. Based on the client's preference.
A. At the level of the heart. Taking a blood pressure at the level of the heart provides the best and most consistent arterial blood pressure reading.
Which pathophysiological findings are characteristic in children with cystic fibrosis (CF)? (Select all that apply.) A. Diabetes mellitus. B. Excessive salivation. C. Abnormal bone ossification. D. Pancreatic enzyme deficiency. E. Hypochloremia and hyponatremia. F. Viscous respiratory secretions.
A. Hypochloremia and hyponatremia. B. Viscous respiratory secretions. C. Pancreatic enzyme deficiency. CF is characterized by exocrine gland dysfunction that produces thick, tenacious respiratory secretions, pancreatic enzyme deficiencies, and abnormally elevated chloride and sodium concentrations in the sweat.
A female client who is newly diagnosed with Type 2 diabetes tells the PN that she hates to exercise and asks whether just following her 1000-calorie diet will control her diabetes. Which response should the PN provide that offers the best information? A. To ensure an increased energy and a sense of well-being, diet and exercise should be balanced. B. Exercise facilitates weight loss and decreases peripheral insulin resistance. C. To improve cardiovascular and respiratory fitness, a regular routine for exercise should be practiced. D. A routine pattern for meal scheduling is needed for tight glucose control.
B. Exercise facilitates weight loss and decreases peripheral insulin resistance. Exercise increases insulin sensitivity and has a direct effect on lowering the blood glucose levels. Dietary compliance and regular exercise contribute to weight loss, which also decreases insulin resistance.
The practical nurse provides information to a client about collecting a 24-hour urine specimen. Which statement indicates the client needs additional information? A. "I should continue to take my prescribed heart medicines." B. "At the beginning of the test, I should add the preservative to the container." C. "I should begin the collection with the first voided specimen when I get up in the morning." D. "At the end of the 24 hours, I should urinate and add this last specimen to the container."
C. "I should begin the collection with the first voided specimen when I get up in the morning." The 24-hour urine collection specimen starts when the client first arises, discarding the first voided specimen, and notes the start time of urine collection.
During a prenatal visit, expectant parents ask the practical nurse (PN) how to safely transport a newborn home in a car seat. What information should the PN provide? A. The car seat should be secured in the front seat using the seatbelt. B. The chest harness should slide over the newborn's abdomen. C. A car seat should be in the rear facing position in the back seat. D. An infant should be elevated at a 60 degree angle while in the car seat.
C. A car seat should be in the rear facing position in the back seat. Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat from birth to 20 pounds and to 1 year of age.
A client who has been taking furosemide (Lasix) for the past two months is 2 days postoperative for a suprapubic prostatectomy. After breakfast, the client is in the bathroom straining to have a bowel movement when he calls the practical nurse (PN) complaining of sudden onset of shortness of breath and acute chest pain. Which condition should the practical nurse (PN) assess the client? A. Stable angina pectoris. B. Pulmonary edema. C. Pulmonary embolism. D. Gastroesophageal reflux.
C. Pulmonary embolism. The client's postoperative status and possible dehydration related to recent use of Lasix places the client at risk for pulmonary embolism, which is a postoperative complication characterized by acute chest pain and shortness of breath precipitated by straining on stool.
The PN is assessing a client who is admitted with a history of heart failure (HF) and a recent onset of dependent edema. Which finding is most important for the PN to report? A. Weight loss. B. Weak, thready pulse. C. Crackles in the lungs. D. Decreased blood pressure.
C. Crackles in the lungs. A client with a history of HF is at risk for cardiac decompensation, so signs of fluid overload, such as dependent edema and crackles in the lungs, should be reported.
Which client receiving infusion therapy is the best assignment for the practical nurse (PN)? A. Client who hemorrhaged and needs a unit of whole blood started on admission to the postoperative unit. B. Client who is receiving diltiazem (Cardizem) IV titrated for a heart rate between 60 to 80. C. Client who requires fingerstick glucose checks while receiving a regular insulin IV solution. D. Older adult client who is confused and has a peripheral saline lock that should to be flushed every eight hours.
D. Older adult client who is confused and has a peripheral saline lock that should to be flushed every eight hours. Client acuity is affected by unstable health alterations that require multisystem organ assessment and determines client care assignments that should be aligned with the PN or registered nurse (RN) scope of practice.
The PN is reviewing the effects of NSAIDs (nonsteroidal anti-inflammatory drugs) with a client who has acute gastritis. What info is correct about the action of NSAIDs? A. Causes histamine receptor stimulation that increases the release of hydrochloric acid. B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining. C. Activates an inflammatory response which increases the drug's absorption. C. D. Stimulates parietal cells to release pepsin leading to digestion of ingested foods.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining.
Regarding client confidentiality, what info represents the correct understanding by the PN of the guidelines set forth by HIPPA? A. Only clients can pick up their prescriptions at a pharmacy B. Past medical records for clients should be stored in a secured place C. Computers that access client info cannot be in public part of nursing station D. Whiteboards with a list of client names are prohibited in areas that the public can see
B. Past medical records for clients should be stored in a secured place
A young child is brought to the emergent care center whose mother is screaming hysterically and states that her child has been beaten. The PN find the UAP crying in the hallway about the child's condition. What action should the PN take? A. Remind the UAP to control her feelings while at work B. Call for the chaplain to come and speak to the UAP C. Support the UAP by going to a private area of talk D. Walk past the UAP to allow for privacy
C. Support the UAP by going to a private area of talk
A child with acute streptococcal pharyngitis is prescribed amoxicillin (Amoxil) suspension. The mother asks the practical nurse (PN) when her child can return to school. Which information should the PN provide? A. After the child is evaluated for complications. B. As soon as the child says the sore throat is better. C. When the child completes 3 days of antibiotic doses. D. After the child has taken antibiotics for 24 hours.
D. After the child has taken antibiotics for 24 hours. Spread of infection of streptococcal disease is common in families, classrooms, and day care centers. After 24 hours, the streptococcal infection should be noninfectious to others.
An infant is admitted to the hospital with a diagnosis of pyloric stenosis. Which finding should the practical nurse (PN) expect to find in the client's history? A. Red current stools. B. Decreased appetite. C. Loose, watery feces. D. Projectile vomiting.
D. Projectile vomiting. Projectile vomiting is a classic symptom of pyloric stenosis, which blocks the exit of gastric contents and causes emesis to be vomited with considerable force.
