Bundle
PN HESI EXIT EXAM
7 Items
2017 PN HESI Exit V3
2017 PN HESI Exit V3 1) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse... [Show More] implement? A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing. D.Return the solution to the pharmacy. Correct Answer: D Return the solution to the pharmacy. 2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not required Correct Answer: B Just prior to tube feeding 3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push. Correct Answer: B Perform synchronized cardioversion. 4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk. Correct Answer: A Pedal pulses will be weak or absent in the left foot. 5) A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins. C.Decrease caloric intake. D.Restrict salt and fluid intake. Correct Answer: D Restrict salt and fluid intake. 6) During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds. Correct Answer: C Monitor the client's serum potassium and blood glucose levels. 7) A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care. Correct Answer: A Determine if all employees have had the hepatitis B vaccine series. 8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing. Correct Answer: D Assess for kinks or dependent loops in the tubing. 9) The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days C.Recently diagnosed type 2 diabetes mellitus D.Skeletal traction for a right hip fracture Correct Answer: B Anorexia and vomiting for the past 2 days 10) The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemia Correct Answer:B Anticholinergic with a side effect of pupillary dilation 11) A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Correct Answer: B The immunization is administered once to older adults or those at risk for illness. 12) The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home. Correct Answer: B While the nurse is taking the client's blood pressure, he has a carpal spasm. 13) During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict the oral fluid intake. Correct Answer: A. Prepare the client for a pericardial tap. 14) After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea. Correct Answer: A Switch to skim milk. 15) A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula. Correct Answer: A. Support the client to a sitting position. 16) A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C.Abdominal cramping D.Dry mucous membranes Correct Answer: A Fever of 102° F 17) A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. Correct Answer: B. Move clients and visitors into the hallways and close all doors to clients' rooms. 18) A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet C.Fluid restriction to 1500 mL/day D.Pentobarbital (Nembutal sodium) at bedtime for rest Correct Answer: D. Pentobarbital (Nembutal sodium) at bedtime for rest 19) A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstruction [Show Less]
- Study guide
- $12.45
- 0
- 587
PN Hesi Exit Exam Questions and Answers V2
PN Hesi Exit Exam Questions and Answers V2 1) The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do w... [Show More] hich to enable the client to best tolerate the ambulation? 1. Provide the client with a walker. 2. Remove the telemetry equipment. 3. Encourage the client to cough and deep breathe. 4. Premedicate the client with an analgesic before ambulating. Correct Answer: 4. Premedicate the client with an analgesic before ambulating. 2) A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? 1. Call a code blue. 2. Call the health care provider. 3. Check the client status and lead placement. 4. Press the recorder button on the ECG console. Correct Answer: 3. Check the client status and lead placement. 3) The LPN/LVN in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position Correct Answer: 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4) The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness Correct Answer: 2. Status of airway 5) The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm Correct Answer: 2. Limiting movement and abduction of the right arm 6) A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The LPN/LVN understands that a life-threatening complication of this condition is which? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction Correct Answer: 3. Pulmonary embolism 7) A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? 1. Smoking history 2. Recent exposure to allergens 3. History of recent insect bites 4. Familial tendency toward peripheral vascular disease Correct Answer: 1. Smoking history 8) The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? 1. "Smoking cessation is very important." 2. "Moving to a warmer climate should help." 3. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm." Correct Answer: 2. "Moving to a warmer climate should help." 9) A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds Correct Answer: 2. Crackles 10) The LPN/LVN is collecting data on a client with a diagnosis of right- sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1. Dyspnea 2. Hacking cough 3. Dependent edema 4. Crackles on lung auscultation Correct Answer: 3. Dependent edema 11) The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? 1. Moderately impaired, and the surgeon should be called 2. Normal, caused by increased blood flow through the leg 3. Slightly deteriorating, and should be monitored for another hour 4. Adequate from an arterial approach, but venous complications are arising Correct Answer: 2. Normal, caused by increased blood flow through the leg 12) A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may stimulate which? 1. Vagus nerve to slow the heart rate 2. Vagus nerve to increase the heart rate 3. Diaphragmatic nerve to slow the heart rate 4. Diaphragmatic nerve to increase the heart rate Correct Answer: 1. Vagus nerve to slow the heart rate 13) A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection? 1. Viral infection 2. Yeast infection 3. Streptococcal infection 4. Staphylococcal infection Correct Answer: 3. Streptococcal infection 14) A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? 1. The boot has not yet dried. 2. The boot is controlling leg edema. 3. The boot is impairing venous return. 4. The boot has been applied too tightly. Correct Answer: 4. The boot has been applied too tightly. 15) A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain? 1. Stable angina 2. Variant angina 3. Unstable angina 4. Nonanginal pain Correct Answer: 2. Variant angina 16) The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen 2. Hyperactive bowel sounds in the area 17) An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? 1. Angry 2. Denial 3. Phobic 4. Obsessive-compulsive Correct Answer: 2. Denial 18) A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure? 1. Intake and output 2. Height and weight 3. Peripheral pulse rates 4. Prior reaction to contrast media Correct Answer: 4. Prior reaction to contrast media 19) A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure? 1. Caffeine 2. Fatty meal 3. Excess sugar 4. Milk products Correct Answer: 1. Caffeine 20) An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a non cardiac problem? 1. "Can you describe the pain to me?" 2. "Have you ever had this pain before?" 3. "Does the pain get worse when you breathe in?" 4. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?" Correct Answer: 3. "Does the pain get worse when you breathe in?" 21) A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1. Strict bed rest for 24 hours 2. Bathroom privileges and self-care activities 3. Unrestricted activities because the client is monitored 4. Unsupervised hallway ambulation with distances less than 200 feet Correct Answer: 2. Bathroom privileges and self-care activities 22) The LPN/LVN is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? 1. Surgical tourniquet 2. Dry sterile dressings 3. Incentive spirometer 4. Over-the-bed trapeze Correct Answer:1. Surgical tourniquet 23) A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? 1. Bed rest, with bathroom privileges only 2. Bed rest, keeping the affected extremity flat 3. Bed rest, with elevation of the affected extremity 4. Bed rest, with the affected extremity in a dependent position Correct Answer: 3. Bed rest, with elevation of the affected extremity 24) A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? 1. Prone with the head on a pillow 2. With the foot of the bed elevated 3. Reverse Trendelenburg's position 4. With the residual limb flat on the bed Correct Answer: 2. With the foot of the bed elevated 25) The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? 1. Bilberry 2. Ginseng 3. Feverfew 4. Evening primrose Correct Answer: 1. Bilberry 26) The LPN/LVN is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1. Wear elastic stockings. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Correct Answer: 2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. 27) A client is at risk for developing disseminated intravascular coagulopathy (DIC). The LPN/LVN should become concerned with which fibrinogen level? 1. 90 mg/dL 2. 190 mg/dL 3. 290 mg/dL 4. 390 mg/dL Correct Answer: 1. 90 mg/dL 28) A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The LPN/LVN should take which action first? 1. Check the client's vital signs. 2. Assist the client to sit or lie down. 3. Administer sublingual nitroglycerin. 4. Apply nasal oxygen at a rate of 2 L/min. Correct Answer: 2. Assist the client to sit or lie down. 29) The LPN/LVN notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? 1. Reviews the intake and output records for the last 2 days 2. Prescribes daily weights starting on the following morning 3. Changes the time of diuretic administration from morning to evening 4. Requests a sodium restriction of 1 g/day from the health care provider Correct Answer: 1. Reviews the intake and output records for the last 2 days 30) A client brings the following medications to the clinic for a yearly physical. The LPN/LVN realizes which medication has been prescribed to treat heart failure? 1. Digoxin (Lanoxin) 2. Warfarin (Coumadin) 3. Amiodarone (Cordarone) [Show Less]
- Exam
- $10.45
- 0
- 576
PN HESI Exit V3
PN Hesi Exit Exam Questions and Answers. 1) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which act... [Show More] ion should the nurse implement? A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing. D.Return the solution to the pharmacy. Correct Answer: D Return the solution to the pharmacy. 2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not required Correct Answer: B Just prior to tube feeding 3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push. Correct Answer: B Perform synchronized cardioversion. 4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk. Correct Answer: A Pedal pulses will be weak or absent in the left foot. 5) A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins. C.Decrease caloric intake. D.Restrict salt and fluid intake. Correct Answer: D Restrict salt and fluid intake. 6) During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds. Correct Answer: C Monitor the client's serum potassium and blood glucose levels. 7) A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care. Correct Answer: A Determine if all employees have had the hepatitis B vaccine series. 8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing. Correct Answer: D Assess for kinks or dependent loops in the tubing. 9) The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days C.Recently diagnosed type 2 diabetes mellitus D.Skeletal traction for a right hip fracture Correct Answer: B Anorexia and vomiting for the past 2 days 10) The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemia Correct Answer:B Anticholinergic with a side effect of pupillary dilation 11) A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Correct Answer: B The immunization is administered once to older adults or those at risk for illness. 12) The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home. Correct Answer: B While the nurse is taking the client's blood pressure, he has a carpal spasm. 13) During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict the oral fluid intake. Correct Answer: A. Prepare the client for a pericardial tap. 14) After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea. Correct Answer: A Switch to skim milk. 15) A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula. Correct Answer: A. Support the client to a sitting position. 16) A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C.Abdominal cramping D.Dry mucous membranes Correct Answer: A Fever of 102° F 17) A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. Correct Answer: B. Move clients and visitors into the hallways and close all doors to clients' rooms. 18) A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet C.Fluid restriction to 1500 mL/day D.Pentobarbital (Nembutal sodium) at bedtime for rest Correct Answer: D. Pentobarbital (Nembutal sodium) at bedtime for rest 19) A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstruction Correct Answer: D Nephron obstruction 20) Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination." Correct Answer: B. "Change your tampon frequently." 21) A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A.Hypoactive bowel sounds with abdominal distention B.Client reports continued pain of 8 on a 10-point scale C.Respiratory rate of 12 breaths/min, with O2 saturation of 85% D.Client reports nausea after receiving the medication Correct Answer: C Respiratory rate of 12 breaths/min, with O2 saturation of 85% 22) A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A.Follow exposure precautions. B.Encourage regular meals. C.Collect all urine. D.Avoid touching the client. Correct Answer: A.Follow exposure precautions. 23) An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions. Correct Answer: A.Initiate airborne infection precautions. 24) Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A.Hypokalemia B.Microalbuminuria C.Elevated serum lipid levels D.Ketonuria Correct Answer: B.Microalbuminuria 25) An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A.Leukocytosis and febrile B.Polycythemia and crackles C.Pharyngitis and sputum production D.Confusion and tachycardia Correct Answer: D Confusion and tachycardia 26) Which nursing action is necessary for the client with a flail chest? A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing. Correct Answer: D Encourage coughing and deep breathing. 27) When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A.A young adult with bacterial meningitis with recent seizures B.An older adult client with pneumonia and viral meningitis C.A female client in isolation with meningococcal meningitis D.A male client 1 day postoperative after drainage of a brain abscess Correct Answer: B An older adult client with pneumonia and viral meningitis 28) When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A.Recommend that the client carry suction equipment at all times. B.Instruct the client to have writing materials with him at all times. C.Tell the client to carry a medical alert card that explains his condition. D.Caution the client not to travel outside the United States alone. Correct Answer: C. Tell the client to carry a medical alert card that explains his condition. 29) A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline. Correct Answer: D.Flush the line with normal saline. 30) In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention? A. The client has a rigid hard abdomen and elevated WBC. B. The client has left lower quadrant pain and an elevated temperature. C. The client is refusing to eat any of the meal and is complaining of nausea. D. The client has not had a bowel movement in 2 days and has a soft abdomen. Correct Answer: A.The client has a rigid hard abdomen and elevated WBC. 31) The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A. "I will read all the teaching booklets you gave me before surgery." B. "I have had surgery before, so I know what to expect afterward." C. "All the things people have told me will help me take care of my back." D. "Let me show you the method of turning I will use after surgery." Correct Answer: D."Let me show you the method of turning I will use after surgery." 32) The nurse on a medical surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected Correct Answer: D If the client's wound is infected 33) The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Do you have frequent blackout spells?" C. "Have you ever been frozen in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" Correct Answer: C. "Have you ever been frozen in one spot, unable to move?" 34) A hospitalized client is receiving nasogastric tube feedings via a small- bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take FIRST? A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump. C.Check placement of the nasogastric tube. D.Measure the amount of residual feeding. Correct Answer: B.Turn off the continuous feeding pump. 35) The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test results Correct Answer: C.Decreased serum ammonia level 36) During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take? A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff. Correct Answer: A.Continue with the shift report and talk to the nurse about the incident at a later time. 37) The LPN/LVN is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption." Correct Answer: "Hold the medication in your mouth for a few minutes before swallowing it." 38) Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A.Stress incontinence B.Infection C.Painless gross hematuria D.Peritonitis Correct Answer: B.Infection 39) A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output. Correct Answer: C.Change the bag when the seal is broken. 40) In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the ABSENCE of a thrill or bruit at the shunt site. What action should the nurse take? A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution. Correct Answer: C.Notify the health care provider of the findings immediately. 41) The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B.Exhibit regular, soft-formed stool within 1 month. C.Demonstrate the irrigation procedure correctly within 1 week. D.Attend an ostomy support group within 2 weeks. Correct Answer: D.Attend an ostomy support group within 2 weeks. 42) A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A.Administer the prescribed dose at the scheduled time. B.Hold the dose and contact the health care provider. C.Hold the dose and recheck the blood pressure in 1 hour. D.Check the health care provider's prescription to clarify dose. Correct Answer: A.Administer the prescribed dose at the scheduled time. 43) A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A.NPO except for metformin and regular snacks B.NPO except for oral antidiabetic agent C.Novolin N insulin subcutaneously twice daily D.Regular insulin subcutaneously per sliding scale Correct Answer: D.Regular insulin subcutaneously per sliding scale 44) The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an OLDER adult most likely to exhibit? A.Polyuria B.Polydipsia C.Weight loss D.Infection Correct Answer: D.Infection 45) The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client INDICATES UNDERSTANDING of the teaching? (Select all that apply.) A. White bread B.Salmon C.Broccoli D.Whole milk E.Banana Correct Answer: B, C, E B. Salmon C.Broccoli E.Banana 46) A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN's insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation. Correct Answer: D Reassign the PN until the resident can be assessed more completely for reality orientation. 47) The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A.A teacher whose blood glucose levels average 126 mg/dL daily with oral anti diabetic drugs B.An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C.A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D.A recovering IV heroin user who contracted hepatitis more than 10 years ago Correct Answer: A.A teacher whose blood glucose levels average 126 mg/dL daily with oral anti diabetic drugs [Show Less]
- Exam
- $17.45
- 0
- 1234
PN Hesi Exit Exam V1
PN Hesi Exit Exam. 1) The LPN/LVN is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8... [Show More] pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stool softener B. Administer prescribed PRN sleep medications. C. Encourage breastfeeding to promote uterine involution D. Encourage use of prescribed analgesic perineal sprays. Correct Answer: A. Administer Prescribed stool softener 2) The LPN/LVN is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area. A. Duodenum B. Gastric Pylorus C. Liver D. Spleen Correct Answer: C. Liver 3) A client comes to the antepartal clinic and tells the LPN/LVN that she is 6 weeks pregnant. Which sign is she most likely to report? A. Decreased sexual libido B. Amenorrhea C. Quickening D. Nocturia Correct Answer: B. Amenorrhea 4) A client's daughter phones the charge nurse to report that the night LPN/ LVN did not provide good care for her mother. What response should the nurse make? A. Ask for a description of what happened during the night B. Tell the daughter to talk to the unit's nurse manager C. Reassure the daughter that the mother will get better care. D. Explain that all the staff are doing the best they can. Correct Answer: A. Ask for a description of what happened during the night 5) A hosptitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? A. Autonomy vs. Shame and doubt. B. Industry vs. Inferiority C. intiative vs. Guilt D. Trust vs. Mistrust Correct Answer: A. Autonomy vs. Shame and doubt. 6) Which action should the LPN/LVN implement in caring for a client following an electroencephalogram (EEG)? A. Monitor the client's vital signs q4h B. Assess for sensation in the client's lower extremities C. Instruct the client to maintain bed rest for eight hours D. Wash any paste from the client's hair and scalp Correct Answer: D. Wash any paste from the client's hair and scalp 7) The LPN/LVN is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus? A. Encourage the client to eat foods high in protein B. Assess the client with daily range of motion exercises C. Teach the family how to perform sterile wound care D. Ensure the IV fluids are administered as prescribed Correct Answer: A. Encourage the client to eat foods high in protein 8) What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space? A. Filtration B. Diffusion C. Osmosis D. Active transport Correct Answer: C. Osmosis 9) The LPN/LVN is taking blood pressure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position? A. Slightly above the level of the heart B. At the level of the heart C. At the level of comfort for the client D. Below the level of the heart Correct Answer: B. At the level of the heart 10) What are the final parameters that produce blood pressure? (select all that apply) A. Heart rate B. Stroke volume C. Peripheral resistance D. Neuroendocring hormones E. Muscle tone Correct Answer: A. Heart rate B. Stroke volume C. Peripheral resistance 11) A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the LPN/LVN to include in this client's plan of care while the client is taking the antidepressant? A. Appetite B. Mood C. Withdrawal D. Energy level Correct Answer: B. Mood 12) Based on the documentation in the medical record, which action should the LPN/LVN implement next? A. Give the rubella vaccine subcutaneously B. Observe the mother breastfeeding her infant C. Call the nursery for the infant's blood type result D. Administer Vicodin one tablet for pain Correct Answer: Give the rubella vaccine subcutaneously 13) A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the LPN/LVN implement to prevent complications associated with Pneumonia? A. Encourage mobilization and ambulation B. Encourage energy conservation with complete bed rest C. Provide humidified oxygen per nasal cannula D. Restrict PO and intravenous fluids Correct Answer: Enourage mobilization and ambulation 14) The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1 gram and the instrutions for reconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only) Correct Answer:15 15) Which nursing activity is within the scope of practice for the practical nurse? A. Complete an admission assessment in the normal newborn nursery. B. Discontinue a central venous catheter that has become dislodged C. Observe a client rotate the subcutaneous site for an insulin pump D. Monitor a continous narcotic epidural for a postoperative client Correct Answer: C. Observe a client rotate the subcutaneous site for an insulin pump 16) After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? A. Identify the need for additional supplies to provide an extra dressing change B. Provide perianal care and collect clean linens for the dressing change C. Document the diarrhea that necessitates an additional dressing change D. Position the client for access to the decubiti sties and remove dressings Correct Answer: B. Provide perianal care and collect clean linens for the dressing change 17) The LPN/LVN is planning to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration in the order from fastest to slowest rate of absorption. Subcutaneous Intravenous Intramuscular Sublingual Oral Correct Answer: Intravenous, sublingual, intramuscular, subcutaneous, oral. 18) A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the LPN/LVN assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? A. Offer to call the social worker to discuss the possibility of abortion B. Reassure the client that the infertility specialist can help C. Express sorrow for the client's grief and offer to sit with her D. Chart the vital signs and amount of vaginal bleeding Correct Answer: Express sorrow for the client's grief and offer to sit with her 19) A terminally ill male client and his family are requesting hospice care after discharge from the hospital and ask the LPN/LVN to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? A. Enhance symptom management to improve end of life quality B. facilitates assisted suicide with the client's consent C. Offers ways to postpone the death experience at home D. Provide training for family members to care for the client. Correct Answer: A. Enhance symptom management to improve end of life quality 20) The LPN/LVN observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take? A. Advise the wife to shave against the hair growth B. Teach the wife to keep the skin loose to avoid cuts C. Encourage the wife to continue shaving her husband D. Demonstrate the correct procedure to the wife Correct Answer: C. Encourage the wife to continue shaving her husband 21) To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply) A. Posterior tibialis artery B. Politeal artery C. External femoral artery D. Dorsalis pedis artery E Radial artery Correct Answer: A. Posterior tibialis artery, D. Dorsalis pedis artery 22) The LPN/LVN is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? A. Smokes one pack of cigarettes daily B. Drinks two beers daily C. Works in a job that requires exposure to the sun D. Eats while lying in bed Correct Answer: A. Smokes one pack of cigarettes daily 23) The LPN/LVN is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catheterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take? A. Stand the client to void and run tap water within hearing distance before catheterizing the client. B. Straight catheterize and if the residual using volume is greater than 100 mL, clamp catheter C. Catheterize q2H and place in an indwelling catheter at the end of the prescribed 24hr period. D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. Correct Answer: D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. 24) A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects? A. Moon face, Slow wound healing, muscle wasting sodium and water retention B. Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbital edema D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension Correct Answer: A. Moon face, Slow wound healing, muscle wasting sodium and water retention 25) The cervix is the opening into the uterine cavity. What is its function in reproduction? A. Accepts and interprets signals of sexual stimuli B. Secretes mucus to facilitate sperm transport C. Serves as the site for union of ovum and sperm D. Receives the penis during intercourse Correct Answer: B. Secretes mucus to facilitate sperm transport 26) The LPN/LVN is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? A. 17-year-old who is sexually active simultaneously with numerous partners B. 34-year old homosexual who is in a monogamous relationship C. 30-year-old cocaine user who inhales and smokes drugs D. 45-year-old who has received two blood transfusions in the past 6 months Correct Answer:A. 17-year-old who is sexually active simultaneously with numerous partners 27) The LPN/LVN is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate? A. Conversion of irregular heart rate to regular heart rhythm B. Pulse oximetry readings within normal range during activity C. Peripheral pulse points with adequate capillary refill D. Increase exercise tolerance without shortness of breath Correct Answer: A. Conversion of irregular heart rate to regular heart rhythm 28) An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? A. Use an over the counter stool softener when needed B. Eat a high protein diet C Increase the fluid intake in your diet D. Decrease the fat content in your diet Correct Answer: C. Increase the fluid intake in your diet 29) The LPN/LVN is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? A. Abnormal skin color changes in a client with dark skin cannot be determined B. Blanching the soles of the feet in a client with dark skin reveals cyanosis C. The lips and mucus membranes of a client with dark skin are dusky in color D. Cyanosis in a client with dark skin is seen in the sclera Correct Answer: C. The lips and mucus membranes of a client with dark skin are dusky in color 30) When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes uring flow into the tubing. What action is taken next? A. Document the color and clarity of the urine B. Insert the catheter an additional inch C. Ask the client to breathe deeply and slowly exhale D. Inflate the balloon with 5mL of sterile water Correct Answer: B. Insert the catheter an additional inch 31) A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? A. Mild electrical stimulus on the skin surface closes the gates of nerve conduction for sever pain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus C. An infusion of medication in the spinal canal will block pain perception D. The discharge of electricity will distract the client's focus on the pain Correct Answer: B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus 32) Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? A. Application of topical antibacterial cream B. Use of careful hand washing technique C. Administration of plasma expanders D. Limiting visitors to the burned client. Correct Answer: B. Use of careful hand washing technique 33) The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? [Show Less]
- Exam
- $12.45
- 2
- 702
PN Hesi Exit V3 Exam Questions and Answers.
PN Hesi Exit Exam V3 Questions and Answers. 1) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which ac... [Show More] tion should the nurse implement? A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing. D.Return the solution to the pharmacy. Correct Answer: D Return the solution to the pharmacy. 2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not required Correct Answer: B Just prior to tube feeding 3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push. Correct Answer: B Perform synchronized cardioversion. 4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk. Correct Answer: A Pedal pulses will be weak or absent in the left foot. 5) A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins. C.Decrease caloric intake. D.Restrict salt and fluid intake. Correct Answer: D Restrict salt and fluid intake. 6) During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A. Review the client's history for diabetes mellitus. B. Observe the extremity distal to the IV site. C. Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds. Correct Answer: C Monitor the client's serum potassium and blood glucose levels. 7) A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care. Correct Answer: A Determine if all employees have had the hepatitis B vaccine series. 8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing. Correct Answer: D Assess for kinks or dependent loops in the tubing. 9) The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days C.Recently diagnosed type 2 diabetes mellitus D.Skeletal traction for a right hip fracture Correct Answer: B Anorexia and vomiting for the past 2 days 10) The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemia Correct Answer:B Anticholinergic with a side effect of pupillary dilation 11) A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. Correct Answer: B The immunization is administered once to older adults or those at risk for illness. 12) The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home. Correct Answer: B While the nurse is taking the client's blood pressure, he has a carpal spasm. 13) During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict the oral fluid intake. Correct Answer: A. Prepare the client for a pericardial tap. 14) After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A. Switch to skim milk. B. Switch to orange juice. C. Add a source of protein. D. Add herbal tea. Correct Answer: A Switch to skim milk. 15) A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A. Support the client to a sitting position. B. Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula. Correct Answer: A. Support the client to a sitting position. 16) A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A. Fever of 102° F B. Blood pressure of 150/90 mm Hg C.Abdominal cramping D.Dry mucous membranes Correct Answer: A Fever of 102° F 17) A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. Correct Answer: B. Move clients and visitors into the hallways and close all doors to clients' rooms. 18) A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet C.Fluid restriction to 1500 mL/day D.Pentobarbital (Nembutal sodium) at bedtime for rest Correct Answer: D. Pentobarbital (Nembutal sodium) at bedtime for rest 19) A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstruction Correct Answer: D Nephron obstruction 20) Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination." Correct Answer: B. "Change your tampon frequently." 21) A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A.Hypoactive bowel sounds with abdominal distention B.Client reports continued pain of 8 on a 10-point scale C.Respiratory rate of 12 breaths/min, with O2 saturation of 85% D.Client reports nausea after receiving the medication Correct Answer: C Respiratory rate of 12 breaths/min, with O2 saturation of 85% 22) A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A.Follow exposure precautions. B.Encourage regular meals. C.Collect all urine. D.Avoid touching the client. Correct Answer: A.Follow exposure precautions. 23) An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions. Correct Answer: A.Initiate airborne infection precautions. 24) Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A.Hypokalemia B.Microalbuminuria C.Elevated serum lipid levels D.Ketonuria Correct Answer: B.Microalbuminuria 25) An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A.Leukocytosis and febrile B.Polycythemia and crackles C.Pharyngitis and sputum production D.Confusion and tachycardia Correct Answer: D Confusion and tachycardia 26) Which nursing action is necessary for the client with a flail chest? A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing. Correct Answer: D Encourage coughing and deep breathing. 27) When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A.A young adult with bacterial meningitis with recent seizures B.An older adult client with pneumonia and viral meningitis C.A female client in isolation with meningococcal meningitis D.A male client 1 day postoperative after drainage of a brain abscess Correct Answer: B An older adult client with pneumonia and viral meningitis 28) When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A.Recommend that the client carry suction equipment at all times. B.Instruct the client to have writing materials with him at all times. C.Tell the client to carry a medical alert card that explains his condition. D.Caution the client not to travel outside the United States alone. Correct Answer: C. Tell the client to carry a medical alert card that explains his condition. 29) A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline. Correct Answer: D.Flush the line with normal saline. 30) In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention? A. The client has a rigid hard abdomen and elevated WBC. B. The client has left lower quadrant pain and an elevated temperature. C. The client is refusing to eat any of the meal and is complaining of nausea. D. The client has not had a bowel movement in 2 days and has a soft abdomen. Correct Answer: A.The client has a rigid hard abdomen and elevated WBC. 31) The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A. "I will read all the teaching booklets you gave me before surgery." B. "I have had surgery before, so I know what to expect afterward." C. "All the things people have told me will help me take care of my back." D. "Let me show you the method of turning I will use after surgery." Correct Answer: D."Let me show you the method of turning I will use after surgery." 32) The nurse on a medical surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected Correct Answer: D If the client's wound is infected 33) The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Do you have frequent blackout spells?" C. "Have you ever been frozen in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" Correct Answer: C. "Have you ever been frozen in one spot, unable to move?" 34) A hospitalized client is receiving nasogastric tube feedings via a small- bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take FIRST? A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump. C.Check placement of the nasogastric tube. D.Measure the amount of residual feeding. Correct Answer: B.Turn off the continuous feeding pump. 35) The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test results Correct Answer: C.Decreased serum ammonia level 36) During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take? A. Continue with the shift report and talk to the nurse about the incident at a later time. B. Ask the nurse to call the house supervisor to see if she must be reassigned. C. Stop the shift report and remind the nurse that all staff are floated equally. D. Inform the nurse that her behavior is disruptive to the rest of the staff. Correct Answer: A.Continue with the shift report and talk to the nurse about the incident at a later time. [Show Less]
- Exam
- $12.45
- 0
- 1213
2019 PN Hesi Exit Exam Questions and Answers
PN Hesi Exit Exam Questions and Answers A school-age client with diabetes is placed on an intermediate- acting insulin and regular insulin before breakfa... [Show More] st and before dinner. She will receive a snack of milk and cereal at bedtime. What does the nurse tell the client the snack is intended to do? You Selected: • Prevent late night hypoglycemia. Correct response: • Prevent late night hypoglycemia. Question 2 A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official’s electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation? You Selected: • “Assessing the official’s medical record is a breach of confidentiality.” Correct response: • “Assessing the official’s medical record is a breach of confidentiality.” Question 3 A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents? You Selected: • Protect your child from infections because his resistance to infection is decreased Correct response: • Protect your child from infections because his resistance to infection is decreased Question 4 The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is: You Selected: • placing the client in isolation. Correct response: • washing the hands frequently. Question 5 A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? You Selected: • in the supine, sitting, and standing positions Correct response: • in the supine, sitting, and standing positions Question 6 A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? You Selected: • cool, pale fingers Correct response: • cool, pale fingers Question 7 A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation? You Selected: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Correct response: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Question 8 A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse? You Selected: • "What activities did you enjoy in the past?" Correct response: • "What activities did you enjoy in the past?" Question 9 A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? You Selected: • nausea, vomiting, and anorexia Correct response: • dyspnea, tachycardia, and pallor Question 10 The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client? You Selected: • Apply firm pressure on the site for 5 minutes after removal. Correct response: • Apply firm pressure on the site for 5 minutes after removal. Question 11 When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse’s priority assessment? You Selected: • checking the dressing, drain, and amount of drainage Correct response: • assessing the vital signs and oxygen saturation levels Question 12 A client with an uncomplicated term pregnancy arrives at the labor- and-delivery unit in early labor saying that she thinks her water has broken. What is the nurse’s best action? You Selected: • Ask what time this happened and note the color, amount, and odor of the fluid. Correct response: • Ask what time this happened and note the color, amount, and odor of the fluid. Question 13 When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes You Selected: • ensuring the abbreviations are understandable to clients who may seek access to their health records Correct response: • limiting abbreviations to those approved for use by the institution Question 14 During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates? You Selected: • "This screening indicates if your baby's lungs are mature." Correct response: • "This test will screen for spina bifida, Down syndrome, or other genetic defects." Question 15 A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? You Selected: • chicken and orange slices Correct response: • chicken and orange slices Question 16 A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse? You Selected: • Collaborate with the interprofessional team to make a referral to social services. Correct response: • Collaborate with the interprofessional team to make a referral to social services. Question 17 A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse’s best response? You Selected: • “No, a spacer is not recommended because it can increase the risk of developing oropharyngeal candidiasis.” Correct response: • “Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs.” Question 18 The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client’s pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client’s vital signs, and the client’s score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next? You Selected: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Correct response: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Question 19 The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia? You Selected: • a client with digoxin toxicity Correct response: • a client with digoxin toxicity Question 20 A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following? You Selected: • A referral. Correct response: • A referral. Question 21 A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first? You Selected: • the client admitted after a head injury in a motor vehicle who reports nausea Correct response: • the client admitted after a head injury in a motor vehicle who reports nausea Question 22 The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate? You Selected: • “Tell me what you’ve found in your reading that’s leading you to that conclusion.” Correct response: • “Tell me what you’ve found in your reading that’s leading you to that conclusion.” Question 23 A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply. You Selected: • Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication. Correct response: • Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication. Question 24 Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next: You Selected: • discuss the situation and possible courses of action with the dietitian and the client. Correct response: • discuss the situation and possible courses of action with the dietitian and the client. Question 25 After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom? You Selected: • fussiness and reports that the cast is heavy Correct response: • inability to extend the fingers on the right hand Question 26 While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response? You Selected: • "I'm sorry, I can't disclose client information." Correct response: • "I'm sorry, I can't disclose client information." Question 27 When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication? You Selected: • urinary retention Correct response: • urinary retention Question 28 Which situation demonstrates correct principles of confidentiality? You Selected: • Two nurses alone in an elevator are discussing a client's status. Correct response: • An emergency department nurse reports suspected child abuse. Question 29 The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, “Why? Everything was going well. How could they do this to me?” What response by the staff nurse reflects an understanding of the client’s borderline disorder? You Selected: • “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.” Correct response: • “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.” Question 30 A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: You Selected: • monitoring the blood glucose level closely. Correct response: • monitoring the blood glucose level closely. Question 31 A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? You Selected: • “The drainage is an indication that the sutures were not tight enough.” Correct response: • “If a wound heals on the surface but infection remains, it will open and drain.” Question 32 A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? You Selected: • Instruct the client to use a pant-blow pattern of breathing. Correct response: • Instruct the client to use a pant-blow pattern of breathing. Question 33 A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it You Selected: • may induce bronchospasm. Correct response: • may induce bronchospasm. Question 34 Bone resorption is a possible complication of Cushing’s disease. To help the client prevent this complication, what should the nurse recommend to the client? You Selected: • Maintain a regular program of weight-bearing exercise. Correct response: • Maintain a regular program of weight-bearing exercise. Question 35 A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief? You Selected: • intravenous (IV) Correct response: • intravenous (IV) Question 36 A client with Parkinson’s disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the mostappropriate action by the nurse? You Selected: • Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment. Correct response: • Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment. [Show Less]
- Exam
- $12.45
- 0
- 894
PN HESI EXIT EXAM 2020 TEST BANK
PN HESI EXIT EXAM 2020 TEST BANK 1. a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What interven... [Show More] tion will the PN implement first? Determine the amount of water and exact time it was taken 2. A client receives ondansetron prior to chemotherapy treatment. How should the PN evaluate this medication? Monitor the client for nausea or vomiting following the treatment 3. The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Has increasing episodes of urinary incontinence 4. The pn determines that a client with cirrhosis is experiencing peripheral....take? Protect the clients feet from injury 5. A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement? Maintain system integrity and to promote lung re-expansion 6. Photo of chest and locating apical HR Just below the left nipple 7. At the end of a 12-hour shift the PN observes the urine in a client’s drainage. What action should the PN take next? Note the most recent white blood count 8. Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? Implement complementary pain relief methods 9. A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. The morning the PN observes that he...Which intervention is most important for the PN to implement? Measure appropriate vital signs 10. The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next? Initiate the urine stream? 11. An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN? Weights are touching the foot of the bed 12. The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take? Encourage the client to continue the dietary changes she has made 13. A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home?-The 6-year old son hits his younger sister during the interview -the 10-year old daughter has circular burns on her trunk and legs -the 3-year old has multiple bruises on the chest and both legs 14. A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining. At what time should the nurse expect to discontinue the intravenous therapy? 1700 15. The PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? Gastric residual volumes 16. A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infants’ mouth. 17. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Deltoid 18. Before inserting medication into a client’s vagina, what instructions should the pn... urinate until bladder is empty 19. An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? A history of untreated gonorrhea can lead to PID 20. A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Wear a supportive bra at all times 21. A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? Self-actualization 22. A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? Explain risks associated with using herbs instead of the prescribed antihypertensives. 23. A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? Act as the clients advocate when discussing the issue with the HCP 24. The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? watch the client for abnormal bleeding 25. ... "it is better to obtain children acetaminophen to prevent possible side effects from the aspirin " 26. A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? neuro-vital signs related to bleeding and intracranial pressure 27. The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of.. total the clients PO intake, fill the water pitchers, empty urinals and catheter bags. 28. While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information.... screening for tardive dyskinesia 29. A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? position client in left lateral position to inspect perianal area for fissures or sacs 30. the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? Begins to show signs of improvement 31. The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? observe the appearance of the urine in the drainage tubing 32. A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report... urinary output of 20 mL/hr 33. The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement? report the findings to the charge nurse 34. The PN is making shift assignment at an extended care rehabilitation...assign to the UAP. -Toileting assistance for a client receiving therapy after a total hip replacement 35. -daily skin care for a client with a descending double barrel colostomy 36. -morning care for a client with a staph wound infection 37. A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? Obtain prescribed calcium gluconate for tetany 38. A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? History of alcohol and tobacco use 39. An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate... Consecutive evening serum glucose readings of >260 mg/dl 40. The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments -A client who is admitted with a suspected ruptured appendix 41. -A client who is post-lumbar puncture is reporting a severe headache 42. -An older male adult with Alzheimers who wanders out of his room 43. -A postoperative client who needs reinforcement of discharge instruction 44. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 45. An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete? Ask about occurrence and frequency of nosebleeds 46. The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. what is most important to reinforce in this clients plan of care? interventions to decrease emotional stress 47. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the the PN, who is taking the client the clients vital signs. What action should the PN implement ? reinforce the need for extra rest periods and plenty of sleep 48. The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing 49. when the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication?` An older client with a stroke who is febrile and confused 50. which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? Report any food injury or sore that does not readily heal 51. during a clinic visit for a sore throat a clients basal metabolic panel reveals a serum potassium of 3.0bmL q/L. Which action should the PN recommend to the client based on this finding? increase intake of dried peaches and apricots 52. A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsals pedis pulse 53. When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Close the door and report the finding to the charge nurse 54. Prior to giving digoxin, the PN assesses that a 2-month old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? give the medication and document the heart rate 55. A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? select all that apply -remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application 56. -place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site 57. -pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads 58. A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tell the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client? direct the client to obtain immediate transportation to the emergency center 59. A client is diagnosed with with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? muscle cramping and dry flushed skin 60. The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectivesnn, which laboratory values should the PN monitor? b,d ABD 61. To obtain an estimate of a clients systolic blood pressure, what action should the PN take first? palpate the clients brachial pulse 62. A client reports feeling numbness and tingling in extremities. What action should the PN implement? review the clients serum electrolyte levels 63. Immediately after birth, which nursing intervention has the highest priority for the newborn infant? preventing heat loss and neonatal cold stress 64. A 0800 a clients apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? determine the level of consciousness 65. which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? urinary output of 50 mL/hour 66. After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention? a client who is trembling and has a glucose level of 50 67. Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinenece maintain standard precautions 68. During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? stimulation of uterine contractions 69. A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? urine output 70. The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? photo is of hospital bed and restraint Is on the bed frame in a bow tie use a full knot to secure the restraint line 71. A new mother asks the pn about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? caput succedaneum will be absorbed and causes no problem 72. The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dL to the nurse. What action should the PN implement next? provide the client with a glass of milk and crackers 73. A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour 74. the PN plans to evaluate an adults response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? pain scale level during walking 75. The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the clients urine is the color of dark tea. What action should the PN take? encourage increased oral fluid intake 76. A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? plasma protein losses resulting in decreased oncotic pressure within the vessels 77. The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? demonstrate to the UAP how to approach the client from the clients left side 78. when assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. he also has a history of gastroesophogeal reflux disease and depression. which interventions is most important for the PN to implement? review the clients use of over the counter (OTC) medications 79. A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? confirm that the desired effect of the medication has been achieved? 80. A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal ? emphasize the importance of active foot flexion 81. A client recovering from a stroke is learning how to use a cane. How should it be placed? on the stronger side of the body 82. A client with schizophrenia is withdrawn isolates himself in the day room and answers questions with one or two word responses which intervention is most important ? measure appropriate vital signs 83. While performing the apical pulse of an adult male client the PN notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for? expected finding 84. A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? give 4 ounces of apple juice 85. A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? provide oral care 86. The PN is caring for a client in bucks tract what is the priority goal for the client in traction? maintain straight body alignment 87. Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? offer emotional support to the family 88. Client voiding small amounts every 24 hours the catherterized volume determines the need to reinsert the indwelling catheter 89. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client? measure all emeisies accurately 90. Single mother of a child with head injury comes crying to the clinic what should the PN tell her? this must seem overwhelming to you right now 91. on admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? erythema and indurations of 5mm at site 92. When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given In the computer. What action should the PN take? contact the medication nurse to clarify the findings 93. A client is admitted for observation after experiencing a TIA high risk for injury 94. Which picture of nailbeds indicate hypoxia? choose the one that has a bump right below the nail bed 95. During morning report the PN learns that an assigned client has phlebitis from a intravenous access device. What will the PN observe in this client? redness, warmth, and edema of the site 96. The PN is caring for a client with atrial fibrillation. What would be an expected finding when assessing this client? heart rate 88 and irregular 97. A clients blood pressure is unusually elevated. Which factors would contribute to this clients blood pressure elevation? stress 98. exercise 99. heart rate 100. body temp 101. During morning report the PN learns that an assigned client has phlebitis from an intravenous access device. What manifestations will the PN assess in this client? palpable cord along the vein 102. How should the PN assist the client to provide sputum sample? coach the client to take deep breaths and cough deeply to mobilize secretions 103. A client with a fever is diaphoretic and the linens are saturated. After assessing the clients vital signs, which action would the PN take? change the bed linens 104. The PN provides a prescribed analgesic perianal spray to a postpartum client. For which problem will this nursing action address? vaginal lacerations 105. The charge nurse is making assignments for client care. Which client would be assigned to the PN for the assessment? client with confusion and sundowner syndrome 106. A client with a chest tube attached to a water sealed drainage system has had 400 mL of drainage over the last 8 hours. After morning care the client was repositioned and the chest tube drainage has been 0 ml for the last 2 hours. What action would the PN take at this time? increase the suction on the drainage system 107. The PN is caring for a client recovering from a transurethral resection of the bladder for prostate hypertrophy. The client has an indwelling urinary catheter and is receiving continuous bladder irigation of sterile normal saline at 100 mL per hour. the health care provider has prescribed to reduce the irrigation to 50 ml/hr if the clients output measurement is equal to 550 mL for 4 hours at which point would the PN reduce the clients bladder irrigation 1000 output measurement 550 mL 108. While inserting an indwelling urinary catheter into a female client the catheter slips into the clients vagina. What would the PN do? keep the catheter in the vagina and insert a new catheter through the urethral meatus 109. Six hours after removing a clients indwelling urinary catheter the client has not voided ad is expressing discomfort from a distended bladder. What action would the PN take? obtain an order for intermittent urinary catheterization 110. During a health history the PN learns that an older client had the chickenpox virus as a child. Which immunization would be indicated for the client at this time? vaccination for shingles 111. The PN is reviewing the state nurse practice act. What information will be included within the document? legal requirements for PN 112. The PN observes a family member provide passive ROM to a client paralyzed upper extremity, The family member is supporting the client elbow by holding above and below the joint through ROM. Which action would the ON take after making this observation? encourage the family member to continue because the procedure is being done correctly 113. a client is diagnosed with respiratory acidosis. What blood pH value will the PN assess when reviewing the clients arterial blood gas results? 7.29 114. A 16 year old client is preceded to receive 1.0 mL of an intramuscular injection. Which sites would the PN consider to administer this medication? deltoid 115. 116. ventrogluteal 117. the PN provides cold packs to the perineum of a postpartum client with perineal hematoma. What will the PN do to evaluate the effectiveness of this action? observe the hematoma for changes in size 118. A client has sustained a burn affecting the clients adipose tissue and blood vessels. Which layer of the clients skin has been affected by the burn? subcutaneous layer 119. During the assessment go a school age child the PN determines that the client is in Ericksons developmental stage of industry vs inferiority. Which behavior did the client demonstrate? sitting quietly reading a book ANSWER SHEET 2019 HESI EXIT PN TEST BANK 120. Flow Sheet 121. Date Hr 1 Hr 2 Hr 3 122. Pad count 2 3 2 123. Urine output 45 mL 35 mL 40 mL 124. TAB 3 - Laboratory Results 125. Date Laboratory Test Results 126. Bilirubin level newborn 14 mg/dL 127. Indirect Coombs' test mother Negative 128. Direct Coombs' test newborn Positive Administer Rh immune globulin 129. A client with type 1 diabetes mellitus has a morning fasting blood 130. glucose level of 70 mg/dL. Which action would the practical nurse take? nothing since this is considered a normal blood glucose level 131. A client with a bee sting has a respiratory rate of 28 and an oxygen 132. saturation level of 80% on room air. What action would the practical nurse 133. take at this time? notify the HCP and prepare to administer O2 134. A school-aged child is given a varicella zoster immune globulin 135. injection. The practical nurse realizes this client has which chronic illness? AIDS 136. The practical nurse positions a client with face and neck burns supine 137. with the neck extended and resting on a rolled towel. Why is this position 138. beneficial to the client? it maximizes neck and face function 139. An obese client asks why a high-protein diet will not help reduce her 140. elevated cholesterol level. What would the practical nurse respond to this 141. client? A high protein diet consist of meat, poultry, and dairy products which are all high in cholesterol 142. A client with an external urinary catheter is complaining of pain. What 143. would the practical nurse do to help this client? remove the external device 144. The lips and mucous membranes of an African-American client are 145. dusty in color. What does this assessment finding suggest to the practical 146. nurse? low oxygen level 147. A client with terminal cancer of the liver wants to leave the hospital and 148. spend time at home before dying. Which action would the practical nurse 149. take to help this client? talk withe the HCP regarding hospice care for the client 150. A client is prescribed a treatment in which the process of filtration will 151. be used. How will the practical nurse explain this cellular transport 152. mechanism to the client? 153. p mechanical pressure forces water and solutes through the membrane 154. A client has an infiltrated intravenous access device in the right arm. To 155. evaluate blood flow to this extremity, which arteries will the practical nurse 156. assess? (Select all that apply.) Brachial 157. radial 158. ulnar 159. The charge nurse is making client care assignments on a busy medicalsurgical 160. care area. Which client would be appropriate to assign to the 161. practical nurse? client recovering from a stroke needing subcutaneous heparin and gastrostomy feedings 162. Prior to administering a prescribed tube feeding to a client with a 163. gastrostomy tube why would the practical nurse aspirate for gastric 164. residual volume? the evaluate the amount of gastric emptying 165. A client is scheduled for an electroencephalogram (EEG). What will the 166. practical nurse instruct the client about this diagnostic test A? you will have electrodes placed on your scalp on your scalp during the test 167. Which action would the practical nurse take to evaluate the hydration 168. status of an infant recovering from abdominal surgery? weigh diapers and assess urine specific gravity 169. A client is prescribed dexamethasone (Decadron) 8 mg by mouth with 170. breakfast. The medication is n contact the pharmacy and ask that the medication be delivered now 171. A client has had a procedure that will result in scarring of the cervix. 172. How will the effects of the procedure impact the client's ability to achieve 173. pregnancy in the future? Restrict the fertilization of the ovum 174. photo of a blood pressure cuff on a clients arm. What would you tell the person palpate the brachial pulse which is on the inside of the arm 175. the PN is preparing to remove an indwelling urinary catheter in a female client. Which action would the PN perform first? deflate the balloon on the catheter 176. Why would the PN provide a bronchodilator to a client with asthma prior to conducting postural drainage? to mobilize secretions 177. There will be pictures of ECG select the one that looks like a bunch of M's 178. Patient has carotid endarterectomy how to observe for signs of bleeding? check area around the neck and elbow 179. pregnant lady reports greenish discharge from vagina nurse should advise the to test for Gonorrhea 180. When repositioning patient the nurse observes wound with a foul odor the nurse should... check the white blood cell count 181. this will be a prioritizing question of which patient to see first the patient with bright red drainage coming out of anus after colonoscopy and polyp 182. patient with dementia is admitted to the unit and is very agitated during the night put patient in room next to nursing station 183. UAP delegations -applying a condom catheter 184. -applying a hearing aid 185. -applying cold packs 186. -assisting to deep breath and cough 187. -blood glucose monitoring 188. -collecting specimens 189. -emptying drainage containers 190. -giving a sitz bath 191. -vaginal douche 192. -recording intake/output 193. -removing a Foley catheter 194. -taking specimens to the lab [Show Less]
- Exam
- $12.45
- 0
- 1069
Purchase the bundle to get the full access instantly
- 3 Million+ Study Documents
- 100% Money Back Guarantee
- Immediate Download Access
Add To Cart
Reviews 0
Bundle Details
$18.45
- Trusted by 800,000+ Students
- 24/7 Money Back Guarantee
- Download is directly available
514
0
Seller Details
