HESI PN
An older male client tells the practical nurse (PN) that his religion does not permit him to bathe daily. How should the PN respond? A. State that the healthcare are provider has prescribed a bath today. B. Offer the client several choices of times to bathe during the day. C. Review the importance of hygienic measures for improved health. D. Request that the client clarify his religious beliefs about bathing.
D. Request that the client clarify his religious beliefs about bathing. A client's religious and cultural preferences should be considered when providing basic hygiene (D). (A,C) provide valid rationale for daily hygiene, but the client's religious beliefs should be considered in the client's choice. Although offering choice (B) addresses client autonomy, the client's care should be individualized.
What action should the practical nurse (PN) take when drawing medication from an ampule? A. Aspirate with a filter needle and syringe B. Tap the bottom of the ampule lightly. C. Snap the neck of ampule towards nurse. D. Use an alcohol swab to open ampule.
A. Aspirate with a filter needle and syringe An ampule is made of glass with a constricted neck that is snapped off to allow access to the medication. Medications are easily withdrawn from the ampule by aspirating the fluid with a filter needle and syringe. Filter needles are used when withdrawing medication from a glass ampule to prevent glass particles from being drawn into the syringe with the medication (A). Tap the top, not the bottom (B) of the ampule lightly to allow all of the medication to drop to the bottom. When opening the ampule, the top should be snapped away from the nurse's face and body (C). An opened alcohol swab wrapped around the top of the ampule may allow alcohol to leak into the ampule (D).
The healthcare provider prescribes a cleansing enema for an adult prior to bowel surgery. Which intervention(s) should the practical nurse implement to ensure adequate bowel cleansing? (Select all that apply.) A. Place the client on left side in Sim's position. B. Use enema fluid that is near 105F C. Repeat enemas until expelled fluid is clear D. Instill 500ml to 1,000 ml fluids slowly. E. Raise the enema container 20 inches above anus. F. Encourage the client to retain 10 to 15 minutes.
A. Place the client on left side in Sim's position. B. Use enema fluid that is near 105F D. Instill 500ml to 1,000 ml fluids slowly. F. Encourage the client to retain 10 to 15 minutes. Placing the client in an optimal position (A), using a sufficient fluid temperature (B) and volume (D) that stimulates peristalsis for an adequate retention time (F) ensures maximal bowl evacuation and cleansing. (C) is not included in the prescription. Fluid instilled at the height of 20 inches (E) can causes excessive pressure and pain, which compromise the client's ability to retain the fluid for proper bowl cleansing.
The practical nurse (PN) is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client? A. Soybeans B. Peanuts C. Whole wheat. D. Sesame seeds.
A. Soybeans Soybeans (A) are the highest in protein quality and contain the most nutritive value. (B,D) are sources of protein but provide less nutritive value. Although whole wheat (C), a complex carbohydrate, should be included in a balanced diet, it is not a protein source.
The practical nurse (PN) is caring for a client who is receiving radiotherapy for cancer of the larynx. Which information should the PN provide the client to reduce the undesirable effected or radiation? A. Use sugarless gum and candy to increase salivary secretions. B. Decrease caloric intake during the course of radiation to prevent nausea. C. Rinse mouth with commercial mouthwashes to decrease oral inflammation. D. Apply oil-based lotions to moisturize dry skin areas that are irradiated.
A. Use sugarless gum and candy to increase salivary secretions. Dry mouth (xerostomia) is often a side effect of external beam radiation to the head and neck. Increasing fluid intake, chewing sugarless gum or sugarless candy (A) or using non-alcoholic mouth rinses or artificial saliva may provide relief (B,C,D) are contraindicated for a client receiving external beam radiation.
A client's indwelling urinary catheter is removed at 9:30am. The practical nurse (PN) assesses the client every 2 hours for the desire to void. Which documented assessment requires further intervention by the PN? A. 1:30pm- unable to void. B. 5:30pm- unable to void C. 3:30pm- unable to void D 11:30 am- unable to void.
B. 5:30pm- unable to void. A client is due to void within 8 hours of catheter removal, so at 5:30pm (B), longer than 8 hours after removal, catheter reinsertion may be necessary. If the bladder is not distended, further action may not be needed at times indicated in (A,C, D)
Which client should the practical nurse consider at greatest risk for bacterial cystitis? A. A middle-aged female who has never been pregnant. B. An older female who does not use estrogen replacement. C. An older male with heart failure. D. A male who uses sildenafil (Viagra).
B. An older female who does not use estrogen replacement. Postmenopausal women who do not use hormone replacement therapy are at an increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina (B). (A,C) are not relevant. Urinary tract infections (UTI) are reported in 3% of men on sildenafil (Viagra) (D) compared to the incidence of UTI in postmenopausal women.
Which food should the practical (PN) recommend for a client to increase the dietary intake of potassium? A. Corn B. Baked potato C. Popcorn D. Grape juice
B. Baked potato A baked potato (B), including its skin, contains the highest amount of potassium. (A,B,D) are low in potassium.
The practical nurse (PN) identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN? A. Heart rate increase of 10 beats per minute. B. Bowel movements decrease to one every third day. C. Urinary output decrease of 250 ml in the last 24 hours. D. Systolic blood pressure decrease of 10 mm Hg.
B. Bowel movements decrease to one every third day. Immobility reduces venous rectum, appetite, fluid intake, and peristalsis, which reduces the frequency of bowel movements and increases the risk for constipation and impaction, which requiring prompt intervention (B). (A,C,D) are expected findings of Immobility, prompt intervention is not required.
An older female recently diagnosed with coronary artery disease (CAD) cooks at home using saturated fats. Which interventions should the practical nurse implement to help the client reduce modifiable risk factors? A. Recommend adoption of a low sodium vegetarian diet. B. Encourage food preparation with various vegetable oils. C. Explain the benefits of a modified exercise program. D. Provide pamphlets which outline CAD risk factors.
B. Encourage food preparation with various vegetable oils. Dietary saturated fats and cholesterol are modifiable risk factors for CAD, so encouraging the use of vegetable oils (B) that are low in saturated fats should help the client learn ways to reduce this contributing factor. (A) may not provide the older client's need for other nutrients, such as protein and calcium. Although (C,D) provide additional ways for healthy heart living, they do not specifically address the client's dietary habits.
An older female recently diagnosed with coronary artery disease (CAD) cooks at home using saturated fats. Which intervention should the practical nurse implement to help the client reduce modifiable risk factor(s)? A. Recommend adoption of a low sodium vegetarian diet. B. Encourage food preparation with various vegetable oils. C. Explain the benefits of a modified exercise program. D. Provide pamphlets which outline CAD risk factors.
B. Encourage food preparation with various vegetable oils. Dietary saturated fats and cholesterol are modifiable risk factors for CAD, so encouraging the use of vegetable oils (B) that are low in saturated fats should help the client learn ways to reduce this contributing factor. (A) may not provide the older clients need for other nutrient's, such as protein and calcium. Although (C,D) provide additional ways for healthy heart living, they do not specifically address the client's dietary habits.
The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers the client his morning blood pressure medication, he refuses to take it. What action should the PN take? A. Mixed the crushed medication in his breakfast oatmeal. B. Explain the importance of routine use of antihypertensives. C. Tell the client that he should not refuse his prescriptions. D. Document that the client refused to take the medication.
B. Explain the importance of routine use of antihypertensives. A client has the right to refuse any medication but should be informed of the therapeutic value of the routine compliance with taking antihypertensive medications (B). Giving medication subversively to alert client. (A) is a violation of his autonomy and is unacceptable. (C) is reprimanding and nontherapeutic. If the client continues to refuse medication after being informed of its value and risk associated with noncompliance, the refusal and reasons should be documented.
The practical nurse (PN) is caring for a client who is admitted with influenza and vomiting for 3 days. The client's skin turgor is poor and oral mucous membranes are dry. Which finding is most important for the practical nurse (PN) to report to the charge nurse? A. Weight loss of 4 pounds in last 3 days. B. Hypotension and tachycardia. C. Nausea and anorexia. D. Dark amber urine output at 30 ml/hour.
B. Hypotension and tachycardia. The client's fluid loss from protracted vomiting causes a shift in intravascular fluids causing dehydration, hypotension and tachycardia (B), which should be reported to the charge nurse. (A,B,C) are signs consistent with dehydration, but the priority is the client's fluid depletion that is causing hypotensive state.
Which technique should the practical nurse use to give a Z-track intramuscular (IM) injection? A. Ensure that no air is present in the syringe. B. Inject the medication into the dorsal gluteal site. C. Select a 22-gauge, 1-inch needle for injection. D. Massage the site for 2 minutes after the injection.
B. Inject the medication into the dorsal gluteal site. The Z-track IM injection technique is used to administer irritating or cutaneous-staining medications into a large muscle, such as the dorsal gluteal site (B) and is given by moving the surface skin to one side before puncturing the skin. The retracted tissue off-sets the needle track, creating the Z-track after is withdrawn, and traps the medication under the realigned tissue. Selecting appropriate equipment (C). checking the syringe for air (A) and using post-injection activities are not part of the Z-track IM technique.
Which technique should the practical nurse use to give a Z-track intramuscular (IM) injection? A. Ensure that no air is present in the syringe. B. Inject the medication into the dorsal gluteal site. C. Select a 22-gauge, 1-inch needle for injection. D. Massage the site for 2 minutes after the injection.
B. Inject the medication into the dorsal gluteal site. The Z-track IM injection technique is used to administer irritating or cutaneous-staining medications into a large muscle, such as the dorsal gluteal site (B), and is given by moving the surface skin to one side before puncturing the skin. The retracted tissue off-sets the needle track, creating the Z-track after the needle is withdrawn, and traps the medication under the realigned tissue. Selecting appropriate equipment (C), checking the syringe for all (A), and using post-injection activated are not part of the Z-track IM technique (D).
A client arrives at the oncology clinic for the next treatment in the prescribed course of chemotherapy (CT). The practical nurse (PN) reviews the client's laboratory results: white blood cells 700/mm3, red blood cells 2.8 million/mm3, hemoglobin 7.9 grams/dl, hematocrit 25.5% and platelet count 14,00/mm3. Which action should the PN take first? A. Obtain the CT from the pharmacy for administration. B. Place an isolation mask on the client. C. Collect a blood sample for type and crossmatch. D. Notify the charge nurse of the client's results.
B. Place an isolation mask on the client. The client is experiencing significant bone marrow suppression, potentially life-threatening compl
Which growth and developmental characteristic should the practical nurse (PN) consider when discussing spirituality with an adolescent client? A. Has a good concept of a supreme being. B. Questions religious practices and values. C. Gives oneself to spiritual tasks D. Accepts the meaning of spiritual faith.
B. Questions religious practices and values. An adolescent often reconsiders child-like concepts of a spiritual power, and in the search for am identity may either question practices and values or find spiritual power as the motivation to seek clearer meaning to life (B). Older adults, not adolescents, often turn to important relationships and give themselves to spiritual task (C). Adolescents do not necessarily have a good concept of a supreme being (A) nor fully accept the meaning of spiritual faith (D) but continue to test and define values and beliefs.
An 80 year old male client who has arthritis and who is having difficulty walking tells the practical nurse (PN). ''It's awful to be old. It seems as though every day a struggle. No one cares about an old person." What is the best response for the PN to provide. A. "its true. We are a youth- oriented society." B. Oh, lets not focus on the negative. Tell me something good." C. "It sounds as though you're having a difficult time. Tell me about it." D. "You're still able to get around, and your mind is as sharp as a tack."
C. "It sounds as though you're having a difficult time. Tell me about it." An essential component of the nurse-client relationship is communicating empathy, which indicates to a client that his feelings are important, so acknowledging the clients difficulty (C) best allows the client to express his feelings. (A,B,D) dismiss the client's verbal and nonverbal communication and do not reflect an understanding of the despair the client is communicating.
Which intervention should the practical nurse (PN) implement to reduce the incidence of urinary tract infections in a client with an indwelling catheter? A. Irrigate the catheter with an sterile distilled water. B. Dilute an antiseptic C. Cleanse perineum area with soap and water BID and PRN. D. Apply an antibiotic ointment around the urinary meatus BID.
C. Cleanse perineum area with soap and water BID and PRN. Daily perineal care BID and PRN should include cleansing of the meatus and catheter junction with soap and water (C). (A,B,D) do not support the concept of medical asepsis and catheter care.
While taking an adults vital signs, the practical nurse (PN) notes an irregular radial pulse. What action should the PN implement to obtain the most the most accurate assessment? A. Use a Doppler for the radial pulse while monitoring the apical. B. Obtain the radial pulse again for one minute followed by the apical. C. Perform an apical-radial pulse assessment with another nurse. D. Verify the finding by counting the apical pulse using a stethoscope.
C. Perform an apical-radial pulse assessment with another nurse An apical-radial pulse provides the most objective comparison when one nurse obtains the radial pulse and another nurse simultaneously auscultates the apical pulse (C). when one nurse collects both rates, either at the same or separate times (A,B,D) the data obtained is less accurate.
A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client's oxygenation? A. Encourage deep breathing prior to suctioning. B. Increase the oxygen flow rate during suctioning attempts. C. Provide oxygen during rest periods between suctioning. D. Limit suctioning attempts to 5 second intervals.
C. Provide oxygen during rest periods between suctioning. When a client is unable to effectively clear respiratory tract secretions with coughing, suctioning with oxygen during rest periods of 10 to 15 seconds between suction attempts (C) should be provided to ensure maximal oxygenation. (B,D) are incorrect. Although encouraging the client to deep breathe (A) increases the effectiveness of hyperoxygenation, suctioning removes oxygen from the airways and is best compensated for with oxygen between suction attempts.
The practical nurse (PN) is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in the client? A. Cyanosis in a client with dark skin is seen only in the sclera. B. Abnormal skin color changes in a client with dark skin cannot be determined. C. The lips and mucous membranes of a client with dark skin are dusky in color. D. Blanching the soles of the feet in a client with dark skin reveals cyanosis.
C. The lips and mucous membranes of a client with dark skin are dusky in color Causes of cyanosis include hypoxemia and decreased cardiac output, which provided clues to respiratory status with changes in skin color and mucous membranes. Cyanosis, a late sign of hypoxia, is best observed in the tissue that has superficial capillary supply, such as mucous membranes, the conjunctivae, lips, palms and under the tongue (C), which is readily visible in dark skin. (A,B,D) do not provide accurate assessment.
A client whose diet is low in fiber is at risk for which condition? A. Hip fracture B. Diarrhea C. Confusion. D. Colon cancer
D. Colon cancer Fiber speeds the movement of substances through the GI tract, reducing the amount of time the colon absorbs water and its exposure to digestive end-products that may be carcinogenic. Low-fiber diets increase the risk for constipation and colon cancer (D). (A,B,C) are unrelated to low-fiber diets.
An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provided the best strategy fro the practical nurse (PN) to implement for the client's incontinence? A. Insert an indwelling urinary catheter. B. Apply absorbent incontinence pads. C. Restricts fluids after the evening meal. D. Establish a 2-hour voiding schedule.
D. Establish a 2-hour voiding schedule. A 2-hour voiding schedule (D) is the best strategy for bladder incontinence management because it provides the client who is confused an opportunity to empty the bladder which minimizes incontinence due to overfilling. Restriction of fluids in the evening (C) is helpful for minimizing nighttime incontinence. Catheter insertion (A) increases the client's risk for infection and should be implemented for associated complications. Although the use of incontinent pads (B) assists with incontinent toileting, the client's episodes of incontinence may continue.
The practical nurse (PN) contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints? A. To decrease the client's agitation and acting-out behaviors. B. To provide an effective way to prevent falls when the client is alone. C. To protect the client and reduce the likelihood of lawsuits. D. To ensure the client's safety when the benefits outweigh the risks.
D. To ensure the client's safety when the benefits outweigh the risks. Restraints should be used when the benefits outweigh the risks in providing a safe environment for the client (D) and ensuring the safety of others. Restraints can increase agitation (A) and are not the most effective way to prevent falls (B). Restraints may provide protection, but must be diligently monitored to prevent negligent injury (C).
Which finding indicated to the practical nurse (PN) that an older client who is receiving intravenous therapy is experiencing fluid overload? A. Edema in lower extremities. B. Crackles in the lungs fields. C. pulse rate of 64 beats/min. D. Respirations of 16 breaths/min.
IV fluid overload in an older client is likely to cause an increase in the workload of the heart causing a decrease in cardiac output. As the left ventricle decompensates, the client manifested crackles in the lung fields (B), an increased pulse rate, and shortness of breathe, not (C,D). Although edema in the lower extremities (A) is consistent with fluid excess, pulmonary crackles are manifested before the onset of third spacing fluids.