HESI PN
Questions with Answer Rationales (100%
Correct)
HESI PN
Questions with Answer Rationales (100%
Correct)
An 80 year old male client who has ... [Show More] 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.
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)
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.
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. [Show Less]
