Out This B!+ch PN Exit Hesi
Prior to administering pain medication to an adult postoperative client, what information should the practical nurse PN obtain? (Select all that apply)
- Time of last administration of pain medication - Client's pain rating on a scale of 1 to 10 - Effectiveness of last pain medication administered
At the beginning of the shift, in which order of priority should the practical nurse PN assess these four clients?
1. An older adult with dizziness who's O2 saturation is 86% 2. An adult woman with vomiting whose potassium is 2.8 mEq/L 3. A young adult with a history of asthma who's arterial pH is 7.48 4. An adult client with an ulcer whose hemoglobin is 9.5 grams/dL
A client consumes 8 ounces of broth, 4 ounces of apple juice, 4 ounces of flavor gelatin and one banana. During the same shift, this client receives one liter of IV fluid and voice 700 ml. How many ml total oral and IV intake should the PN document on the client's medical record?
1480
The practical nurse (PN) is obtaining fetal heart rates on four antepartum clients in their third trimester of pregnancy. Which fetal heart rate should be reported to the registered nurse RN immediately?
180
A mother ask the practical nurse (PN) about the immunazation schedule for whooping cough. Which is the recommended schedule that the PN should convey?
2.4.6 months, and boosters at 15 to 18 months and 4 to 6 years of age.
A client receives a prescription for cefaclor suspension 325mg that mouth every 8 hours. The bottle is labeled, cefaclor for oral suspension, USP 375 mg per 5 ml. How many ml should the practical nurse (PN) administer?
4.3
The practical nurse (PN) is giving medications to a client who was admitted to the hospital with a diagnosis of diabetes mellitus. After checking the finger stick glucose at 1630, which dose of insulin should the (PN) administer?
8 units
The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first?
A preschooler who had an emergency appendectomy for appendicitis
The practical nurse PN is auscultating a client's lung sounds. Which description should the PN use to document this sound?
Fine crackles
A chronically depressed older male resident of a long term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much in the past. Which comment by the practical nurse (PN) is likely to be most helpful to the client?
May I sit with you for a while
A client receive Ondansetron Prior to a chemotherapy treatment. How should the practical nurse evaluate the effectiveness of the medication?
Monitor the client for nausea or vomiting following the treatment
A client is receiving an anticonvulsant, diazepam, intravenously for status epilepticus.Which intervention is most important for the practical nurse (PN) to implement?
Monitor the client's respiratory rate and effort
The practical nurse (PN) overhears a female client with Cushing's syndrome tell her family in a very loud an angry voice to leave her room and not to come back. The response by the PN is based on recognizing which common manifestation of the syndrome?
Mood alterations
The practical nurse (PN) notices that one of the unlicensed assistive personal (UAP) working in long term care facility consistently records subnormal temperatures when using a tympanic thermometer. Which action should the PN take first?
Observe how UAP obtains temperatures
The practical nurse peer views the midline episiotomy of a client whose reports pain in her stitches. Which action should the PN take first?
Observe suture line for separation and hematoma formation
A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. What manifestations warrant immediate intervention by the PN?
Pulse oximetry of 88% O2 saturation.
The practical nurse PN determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?
Pupils reactive to accommodation
Which finding for a client with an arteriovenous Fistula (AV fistula) should the practical nurse PN report to the healthcare provider?
Radio pulse distal to AVF is absent and ulnar pulse is presentB. bruising at the AVF site is purple and green in color
An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she wasconfused prior to admission. What action should the practical nurse (PN) take?
Remind the client what day of the week it is
The practical nurse explains to a client how to obtain a sputum specimen and the client indicates understanding the procedure. After the PN leaves the room the client obtains the specimen and notifies the PN. When the PN arrives to collect the specimen it appears as seen in the picture. Which action should the PN take.
The PN should teach the client to a client how to obtain a septum specimen and if the client does not correctly collect the specimen the PN should assist the client in obtaining another specimen coughed directly into a sterile cup
An older postoperative client has the nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse (PN) actions forthis client?
The PN will place a gait belt on the client prior to ambulation.
The practical nurse (PN) observes an infant searching for a fallen toy. According to Piaget which additional finding should the PN correlate with this developmental stage?
Exploration beyond caregiver presence
Which food provides the best source of vitamin B12?
Hamburger
The practical nurse (PN) is checking residual volume prior to administration of a bolus feeding to a client with a percutaneous endoscopic gastrostomy (PEG) tube when the unlicensed assistive personal (UAP) reports that another client has requested pain medication for postoperative pain. Which action should the LPN take?
Have the UAP notify the client in pain that the PN will be in to check on the client after completing the procedure in process
A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the practical nurse (PN) identifies that unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missingcomponent, which action should the PN take?
Supervise the UAP after reviewing the protocol
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 includes continuation of all home medication. Which medication should the practical nurse (PN) withhold until consulting with the charge nurse?
Aspirin
The practical nurse (PN) determines that a client who is one day postpartum has a moderate amount of loch and the uterus is firm, dextroverted and three finger breadths above the umbilicus. What should be the PN's initial action?
Assess the bladder for distension.
The practical nurse (PN) is assigned to care for a client who had an endoscopic procedure in which the local anesthetic was sprayed on the throat. Which priority actionshould the PN include in the clients plan of care?
Assess the gag reflex
An older client with metastatic breast cancer is experiencing shortness of breath as the result of bilateral pneumonia. The client has a living will, and the family is requesting hospice care. Which information should the practical nurse (PN) reinforce with the clientand family regarding hospice care? (Select all that apply.)
- Care can be provided in the home where the client resides - Care focuses on comfort, dignity, and emotional support - Instructions for care should be included in the client's living will
The practical nurse (PN) administer an antibiotic to a client with a respiratory tract infect. To evaluate the medication effectiveness which laboratory values she the PN monitor? (Select all that apply.)
- Sputum culture and sensitivity - White cells blood count
The practical nurse pin is assigned to care for a client who had in endoscopic procedure in which a local anesthetic was sprayed on the throat. Which priority actions should the PN include in this client's plan of care?
Assess the gag reflux
The practical nurse (PN) is assigning care for a group of clients on the urology medicalunit. Which client should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- Empty beside drainage unit for a client with indwelling urinary catheter - Transport a urine culture sample to the laboratory
The health care provider gives a pregnant woman a prescription for one prenatal vitamin with iron daily and tells her that she needs to increase iron rich foods in her diet because her hemoglobin it's 8.2 grams/dl. When a list of iron rich foods is given to the client, she tells the practical nurse PN that she is vegetarian and does not eat anything that bleeds. Which instruction should the (PN) provide? (Select all that apply)
- Increase green leafy vegetables in the diet - Add lentils and black beans to soups - Oatmeal is a good choice for breakfast
An order client with metastatic breast cancer is experiencing shortness of breath as a result of bilateral pneumonia. The client has a living will, and the family is requesting Hospice care. Which information should the practical nurse (PN) reinforce with the client and family regarding Hospice care? (select all that apply)
- Instructions for care should be included in the client's living will - Care can be provided in the home where the client resides - Care focuses on comfort, dignity, and emotional support
A 2-day old infant with hydrocephalus returns from surgery following placement of a ventriculoperitoneal shunt. Which nursing interventions should the practical nurse PN implement during postoperative care? (Select all that apply)
- Measure head circumference daily - Document strict intake and output - Monitor body temperature every four hours
The nurse is very busy and running late with administering medications and asks thepractical nurse (PN) to administer a medication already drawn up in an unlabeled syringe. How should the PN respond?
"I am not comfortable doing that. Is there something else I can do to help you?"
The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use?
- Position client in left lateral recumbent position to expose buttocks. - Encourage client to retain solution for at least 5 minutes. - Insert lubricated tip of tubing 3 to 4 inches into the rectum.
The practical nurse peeing is documenting the insertion of a urinary catheter for a female client with urinary retention. Which information should the PN include during the electronic documentation of the procedure? (Select all that apply)
- Size of urinary catheter - Amount of urine obtained - Appearance of urine obtained
The practical nurse (PN) is assisting the recreational director of a long term care facility plan outdoor activities for the wheelchair-bound older residents who're mentally alert. Which activity meets the physical and social needs of these residents?
A team ring-toss competiton
The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client's radial pulse as seen in the picture. Which action should the PNtake?
Demonstrate the correct pulse site to the UAP (follow the thumb for the radial pulse,follow the pinky for the brachial)
The practical nurse (PN) and unlicened assistive personal (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphare. Which action should the PN implement?
Demonstrate to the UAP how to approach the client from the client's left side
The practical nurse PN learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?
Ability to swallow
An older male resident of a long-term care facility is awake at 3:00 AM and wandering down the hall with his pajamas unbutton. Which intervention should the practical nurse PN implement?
Address the client to determine his needs
The practical nurse (PN) observes a newly hired PN who is preparing to open an ampule as seen in the picture. Which action should the PN take?
Advised the newly hired PN to reposition the alcohol pad around the neck of ampule
The parents of a one-year-old child with the diagnosis of hypospadias informed the practical nurse PN that they plan to delay corrective surgery to see if the child will outgrow the problem. Which information should the PN provide to these parents?
Ask the parents to explain what they understand about the child's diagnosis
The practical nurse (PN) is working in a cancer detection mobile clinic. Four individuals come for screening with a complaint of hoarseness, a dangerous sign for cancer of the larynx. Which client has the highest risk for development of cancer of the larynx that the PN should refer to the healthcare provider?
An older male who drinks a six pack of beer nightly and smokes heavily
The practical nurse (PN) ask an unlicensed assistive personnel (UAP) for feedback about an assigned client instead of responding, the UAP walks away from the PN, ignoring the question. What action is best for the PN?
Approach the UAP to discuss the behavior and obtain the information needed about the client
Client who is in active labor is admitted with her cervix dilated to 3 cm with 50% effacement and presenting part a 0 station. An hour later she tells the practical nurse (PN) that she wants to go to the b bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged. Which action should the PN implement?
Assist the client up to the bathroom.
Which intervention is within the scope of practice for a practical nurse (PN)?
Demonstrating deep breathing and coughing to a postoperative client
The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds (4,581 grams). The infant is jittery and has a heel stick glucose level of 40 mg/dL(2.2 mmol/L or SI units) 30 minutes after birth. Based on this information, which intervention should the practical nurse (PN) implement first?
Begin frequent feedings of breast milk or formula
The practical nurse (PN) notifies the healthcare provider about client information usingSituation, Background, Assessment, Recommendation (SBAR) technique. Which information should the PN provide first?
Blood pressure is 80/48 mmHg
A college student arrives at the clinic for a physical examination and asks the practical nurse (PN) how he should perform testicle self-examination TSE. Which information should PN provide?
Examine the testicles during bathing
The practical nurse (PN) observes hematuria in the urinary catheter drainage tubing of aclient who is receiving intravenous heparin. Which action should the PN implement first?
Check the client's gums for bleeding
The practical nurse (PN) notifies the health care provider about client information using the situation, background, assessment, recommendation SBAR technique. Which information should the PM provide first?
Cholecystectomy 24 hours ago
Which finding should the practical nurse (PN) report to the registered nurse (RN) immediately?
Coffee-ground secretions draining via nasogastric tube suction.
The practical nurse PN is performing stomach care with the client. While cleaning around the stoma, the PN notices blood on the washcloth. Which action should the PN take next?
Continue to clean around the skin surrounding the stomal site
The practical nurse (PN) explains the 2-week dosage prescription of prednisone to a client who has poison ivy covering multiple skin surfaces. What should the PN emphasizeabout the dosing schedule?
Decrease dosage daily as prescribed
While administering prescription medications to an older resident in an extended care facility, the practical nurse (PN) notices that the client is having difficulty hearing. What action is most important for the PN to take?
Determine if the client has had difficulty in the past
When obtaining a capillary blood sample for glucose measurement, which interventionshould the practical nurse (PN) implement?
Determine which finger was used previously
While assisting the RN with the admission of a toddler, which intervention should the practical nurse (PN) implement to make the experience least stressful for the child?
Do a complete head-to-toe exam in sequence
In caring for a client with bucks traction, the practical nurse (PN) observes that the prescribed amount of weights are hanging freely and the traction rope is on the pulley. Which action should the PN implement next?
Document that the Buck's traction is being maintained
A client is diagnosed with Clostridium difficile. Which action should the practical nurse (PN) implement to prevent the spread of Organism?
Don non sterile gloves when performing direct care
The practical nurse (PN) reviews instructions for use of polyethylene glycol, a laxative,with a client scheduled for a colonoscopy. Which instruction should the PN include?
Drink each glass of solution rapidly at regular specified time intervals
The practical nurse (PN) plans to use distraction techniques while a client undergoes abrief painful procedure. Which action should the PN implement during the procedure?
Encourage the client to reminisce about a favorite past family event
An older client who had a colon resection 8 days ago is straining at stool. The practical nurse (PN) observes sudden spillage of serosanguinous Drainage from the client's wound followed by appearance of bowel on the skin. Which complication has occurred?
Evisceration
The spouse of a hospitalized client asked the practical nurse PN for acetaminophen for tension headache. Which action should the PN take?
Explain that medication can only be provided to clients.
When assessing a client at 38 weeks gestation, the practical nurse (PN) determines that she has one set of female twins, who are now 6 years old, a son who is 4 years old and last year she had a fetal loss at 24 weeks gestation. Which is the correct graviditiy for this client?
Gravida-4 Para-3
Which statement by a mature adult client with advanced prostate cancer best indicatesthat he has reached a level of acceptance of his prognosis?
I've found the support I need from my faith and family
When a small fire breaks out in the kitchen of a long-term care facility, which task ismost important for the practical nurse (PN) to perform instead of assigning to a unlicensed assistive personnel?
Identify the method for transporting and evacuating each resident
The practical nurse PN is assisting with the plan of care for a client with costochondritis who is now experiencing increased discomfort in breathing. The client receives a prescription for tramadol. What intervention should the PN include in the client's plan of care?
Implement ongoing assessments for signs of shallow or slow breathing
The practical nurse (PN) is caring for a client with fractured metatarsals after slamming a hand in the car door. After administering the prescribed hydrocodone/acetaminophen for pain, which intervention should the PN include in the clients care?
Implement ongoing assessments for signs of shallow or slow breathing.
Which instruction is most important for the practical nurse (PN) to reinforce in the discharge teaching of a 16 year old who had above the knee amputation (AKA)?
Inspect the residual limb everyday
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the P end to the client's silence is best?
It's OK if you don't want to look or talk about the mastectomy I will be available when you're ready
Which intervention should the practical nurse (PN) reinforce for a client with pruritis?
Keep fingernails trimmed short
The practical nurse is caring for a client who has a fractured right tibia and fibula. To reduce swelling and promote comfort, the PN should place the client in which position?
Left lateral recumbent position with the right leg supported in proper alignment
The Glasgow coma scale is being used to monitor a client who experience a traumatic brain injury. What primary assessment should the practical nurse PN evaluate?
Level of consciousness
While turning and positioning a bit fast client, the practical nurse (PN) observes that the client is dyspneic. Which action should the PN take first?
Notify the charge nurse
A male preoperative client who has already signed the informed consent for a surgicalprocedure confides to the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?
Notify the charge nurse of the client's concerns about surgery
The practical nurse (PN) is caring for a client who has been taking nonsteroidal anti- inflammatory drug ibuprofen for arthritic pain. Which action will the PN include in thisclient plan of care?
Observe for signs of gastrointestinal bleeding
The practical nurse (PN) administers filgrastim to a client with neutropenia. The clientlater complains of bone pain. Which action should the PN take?
Offer to administer a prescribed PRN analgesic to the client
The practical nurse peeing and ministers an anticonvulsant That causes photosensitivity. Which action should the PN take after administering the medication?
Remind the client to protect skin from sunlight
A client who had orthopedic surgery 3 days ago complains of difficulty sleeping. Which initial intervention is best for the practical nurse (PN) to implement?
Reposition the client and provide a back rub
When gathering data about a client with dark skin tones, which site should the practicalnurse (PN) observe?
Sclera and mucous membranes
The practical nurse (PN) is observing a client self-administering a dose if subcutaneousinsulin. What step of the injection technique should the practical nurse (PN) reteach?
Selects the same site that was used for the previous injection
A client who is primigravida at term comes to the prenatal clinic and tells the practical nurse (PN) That she is having contractions every 5 minutes. The PN monitors the client for one hour using an external fetal monitor, and determines that the client's contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. Which action should the PN take?
Send the client home and instruct her to call the clinic where her contractions occur 5 minutes apart for one hour
The practical nurse (PN) is assisting a client to cough and deep breathe following surgery.To facilitate effective coughing, the PN should assist the client to assume which position?
Sitting on the side of bed with feet flat on the floor
An older client tells the home health practical nurse (PN) about experiencing dizziness when getting out of bed. Which assessment is most important for the PN to obtain?
Standing blood pressure
Which finding should the practical nurse (PN) instruct the postpartum client to report to the charge nurse?
Sudden or persistent temperature above 100.5 F (38.0 C).
A practical nurse (PN) is at the nurses' station describing her social life, sexual activities,and alcohol drinking in a boisterous voice that might be heard by clients and visitors. What is the best action that a peer nurse should do?
Suggest going to the nurses' lounge if she needs to discuss these topics
A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size then the one the PN is trying to give him now. How should the PN respond?
Tell the client that the PN will verify that the dispense medication is the valid prescription
A client who is being cared for in her home has a low serum sodium level of 125 mEq/L. To determine the cause of this value, which information should the practical nurse (PN) request from the client?
The amount of ice chips and water consumed daily
The practical nurse (PN) it's changing the abdominal dressing for a male client who was discharged home following a colon resection. Which information should the PN report to the healthcare provider?
The client reports the wound care is painful and would like a prescription for an analgesic
An older postoperative client has the nursing diagnosis, impaired mobility related to fear of falling which desired outcome best directs the practical nurses PN actions for the client?
The client will ambulate with assistance Q4 hours
The PN is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission?
The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias
The single mother of a child with a head injury is sitting at the child's bedside crying when the practical nurse (PN) enters the room. The mother states, why did this happen to my child? I just can't cope with this, what is the best initial response by the PN?
This must appear devastating to you at this moment
The practical nurse (PN) assesses a child in 90-90 skeletal traction. It is most important for the PN to assess for signs of information at what location?
Toe
The practical nurse (PN) preparing to assist an elderly client to the bathroom. The PN knows that an elderly adult's center or gravity changes from the hips to another area of the body. And planning to safely assist this client the PN knows that the center of gravity for the elderly client is in which area of the body?
Upper torso
Which client information is most important for the PN to consider when providing instructions to the unlicensed assistive personnel about providing morning care to a postoperative client?
Urinary output of 50 mL/hour.
In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?
Use a gloved finger to rub the suspension over the infected area
The practical nurse is caring for a client receiving a prescription for paroxetine who suddenly exhibits restlessness, tachycardia, fever, and elevated blood pressure. Which action should the PN implement first?
Withhold the next dose and contact the health care provider
