Foundations HESI Questions and Answers
Foundations HESI Questions and Answers (All Correct)
1. The practical nurse (PN) is providing skin care to
... [Show More] an older male client who has the tendency to stay on his left side in a lying position. Which bony prominence should the PN identify as the site most likely to develop alterations in skin integrity?
A. Ilium. Correct
2.
The practical nurse (PN) is preparing to give a complete bed bath to an unconscious client. After implementing standard precautions before the procedure, what action should the PN implement next?
A. Wash each eye with a fresh area of a washcloth before washing the rest of the face. Correct
3.
When providing perineal care for an uncircumcised male client, the practical nurse (PN) should implement which action?
A. Retract the foreskin before cleansing the glans and replace the foreskin after the procedure. Correct
4.
The healthcare provider prescribes a vest restraint for an older male resident in a long-term facility who frequently falls out of his wheelchair. Which action should the practical nurse (PN) implement?
A. Remove device every 2 hours and change client’s position. Correct
5.
The healthcare provider prescribes wrist restraints for a client who is agitated and combative. Which action should the practical nurse (PN) implement?
A. Check the client's skin color, warmth, and pulses distal to the restraining device. Correct
6.
A client who is placed in wrist protective devices begins to complain of pain and swelling in one hand. The practical nurse (PN) notes that both hands are cool and pale. What action should the PN implement?
A. Remove both devices and notify the healthcare provider. Correct
7.
The practical nurse (PN) notifies the healthcare provider that a male client has become combative and needs a protective device to prevent injury to self and others. Which principle should the PN use when selecting a protective device?
A. A protective device provides the least amount of immobilization. Correct
8.
The practical nurse (PN) hears an auscultatory gap in the Korotkoff sounds of an older client with hypertension. What action should the practical nurse (PN) implement when obtaining the client's blood pressure?
A. Continue to listen for the next Korotkoff sound until the cuff is deflated. Correct
9.
The practical nurse (PN) obtains an irregular pulse rate of 102 beats/minute for a client with a history of cardiac disease. Which action is most important for the PN to implement?
A. Listen to the apical rate for one full minute. Correct
10.
For several days after her husband's death, a client who is admitted with acute depression repeats over and over, "I should have made him go to the doctor when he said he didn't feel well." Which descriptor should the practical nurse use to document the client's feelings?
A. Guilt. Correct
11.
Which client group is most likely to experience a therapeutic response from therapeutic touch?
A. Clients with headaches. Correct
12.
An older client is receiving normal saline at 83 ml/hour per gravity. At the end-of-shift assessments, the practical nurse (PN) calculates the client's intake and output and determines that the infusion delivered 500 ml in the last hour. Which action should the PN take first?
A. Auscultate the lungs for crackles. Correct
13.
Which action should the practical nurse (PN) implement to minimize the risk of hypernatremia for an older client?
A. Offer fluids on a set schedule throughout the day. Correct
14.
A client's serum potassium level is 2.9 mEq/L. Which is the most important finding that the practical nurse (PN) should report to the charge nurse?
A. Pulse rate weak and irregular. Correct
15.
An unlicensed assistive personnel (UAP) tells the practical nurse (PN) that another nurse on the unit is acting disrespectfully. What action should the PN implement?
A. Tell the UAP to share feelings with the nurse. Correct
16.
The practical nurse (PN) is collecting data from clients' electronic medical records for the nurse manager's quality assurance review about documentation of client pain relief. What information should the PN include as the best measure of pain relief?
A. Client pain intensity documented 1 hour after analgesia. Correct
17.
The practical nurse (PN) is preparing to reinforce information with a client who has chronic pain. Which learning objective should the PN review?
A. Recalls two nonpharmacological interventions used to relieve pain. Correct
18.
The practical nurse (PN) is calculating an 8-hour intake for a postoperative client. Based on the client's bedside record, how many ml of intake should the PN enter in the client's electronic record? (Enter numeric value only.) One cup of coffee One 8-ounce glass of iced tea One 6-ounce dish of flavored gelatin One-half cup of chicken broth
Correct
Correct Responses
A. 780
19.
The family of a male client with terminal cancer decides to not tell the client about his prognosis. The client has asked the practical nurse (PN) several times if he is dying. What action should the PN implement?
A. Discuss the client's frequent questions with family and healthcare provider. Correct
20.
The practical nurse (PN) is reviewing discharge information with a client who is positive for HIV. Which action should the PN reinforce with the client to help prevent transmission of HIV?
A. Disinfect areas contaminated with body fluids using 1:10 bleach solution. Correct
21.
What findings should the practical nurse (PN) document to describe infiltration at a client's intravenous (IV) site?
A. Edema and cool skin at insertion site. Correct
22.
The practical nurse (PN) is administering eye drops to a client with glaucoma. Which technique should the PN implement to ensure the eyes drops are effectively absorbed topically?
A. Tell the client to move closed eyes from side to side. Correct
23.
The practical nurse (PN) is assigned the PM care of six clients on a medical surgical unit whose morning laboratory results are not available. What action should the PN take?
A. Call the laboratory to ask if the clients' test results are ready. Correct
24.
The practical nurse is administering otic drops to an adult client with otitis externa. Which action describes the correct administration technique?
A. Pull the pinna of the ear up and out. Correct
25.
The practical nurse (PN) uses the SBAR format to report an acute client situation to the healthcare provider. Which information is the correct understanding of this method?
A. The "R" stands for recommendation and suggests an action for the healthcare provider. Correct
26.
A client is admitted with bacterial meningitis. Which intervention is most important for the practical nurse (PN)?
A. Implement droplet precautions. Correct
27.
A male client with coffee ground emesis is admitted with a hemoglobin of 10.2 grams that is now 7.5 grams/dl since admission. The client's blood is typed and crossmatched for 2 units of blood, and the healthcare provider prescribes STAT administration of one unit. The client indicates to the practical nurse (PN) that he wants to shower first. Which intervention should the PN implement?
A. Explain the need for starting the transfusion immediately. Correct
28.
The practical nurse (PN) is reinforcing self-care with a male client who is being discharged with an ileostomy. Which client behavior best indicates to the PN that he understands ileostomy care?
Empties the ileostomy appliance bag when it is about one-third full. Correct
29.ID: 14033297123
The practical nurse (PN) is documenting the administration of a client's medication. Which entry by the PN complies with The Joint Commission (TJC) guidelines for use of abbreviations?
A. Doses of clonidine 0.15 mg given AC BID. Correct
L. 30.ID: 14033297149
The practical nurse (PN) is assisting the nurse in the administration of a unit of blood to a client with AB positive blood type. Which finding should the PN identify as a policy standard that should be addressed first?
A. The client does not have an identification bracelet. Correct
M. 31.ID: 14033296489
When determining if the client is compliant with a prescribed medication regimen, which question is best for the practical nurse (PN) to ask?
A. "When and where do you take this pill at home?" Correct
N. 32.ID: 14033297127
When should the practical nurse (PN) reinforce teaching to a client about a daily surgical dressing change?
A. During the next dressing change. Correct
O. 33.ID: 14033298037
A male client who walks in the clinic begins talking to the practical nurse (PN) with slurred speech. Which action should the PN implement first?
A. Ask the client how he is feeling today. Correct
P. 34.ID: 14033297116
The practical nurse (PN) is planning morning care for a client with gastrointestinal bleeding and a hemoglobin level of 8.1 grams/dl who is scheduled to receive a unit of packed red blood cells (PRBC's). Which action should the practical nurse (PN) take?
A. Initiate serial vital signs before and during the transfusion. Correct
Q. 35.ID: 14033297187
Which intervention is most important for the practical nurse (PN) to implement to decrease the number of falls for clients in a long-term care facility?
A. Inquire about the client's level of pain.
B. Ask about the need to use bathroom. Correct
R. 36.ID: 14033298059
The practical nurse (PN) is caring for a client who begins to vomit copious amounts of blood. What action should the PN do first?
A. Use a Yankauer-tip device for oropharyngeal suction. Correct
S. 37.ID: 14033297121
The practical nurse (PN) is giving iron dextran (Imferon) 250 mg IM using the Z-track method to a client with anemia. Which needle should the PN select for this injection?
A. 2-inch, 19 gauge needle. Correct
T. 38.ID: 14033298055
The practical nurse (PN) is obtaining a blood specimen from a client's peripherally inserted central catheter (PICC). What action should the PN to implement first?
A. Discard first 5 ml of blood sample. Correct
U. 39.ID: 14033297139
A client who has a tunneled Hickman catheter for hemodialysis receives a prescription for IV antibiotics. Which action should the practical nurse take?
A. Utilize a peripheral IV access to administer IV antibiotics. Correct
V. 40.ID: 14033298053
The practical nurse (PN) finds an older female client lying on the floor. What action should the PN take first?
A. Obtain the client's vital signs. Correct
W. 41.ID: 14033297189
The practical nurse (PN) is preparing to change the abdominal dressing for a client who had abdominal surgery yesterday. When should the PN reinforce teaching about the client's dressing change?
A. During this dressing change. Correct
X. 42.ID: 14033297177
A client presents to the emergent care center reporting chest pain and feeling "lightheaded," as if he is "going to faint." What is the most important action the practical nurse (PN) should implement?
A. Place client in a chair or upright on a stretcher. Correct
Y. 43.ID: 14033298033
The practical nurse (PN) is obtaining blood specimens from a client. After inserting the needle into the arm, the client screams and reports an electric "shooting" pain in the arm. What action should the PN implement?
A. Withdraw the needle from the arm. Correct
Z. 44.ID: 14033297137
A client with Clostridium difficile is placed on isolation precautions. Which transmission-based precaution should the practical nurse implement?
A. Wear gown and gloves when rendering direct care. Correct
AA.45.ID: 14033297114
The practical nurse (PN) stops to help at a serious motor vehicle collision site and applies pressure to one of the victim's neck that is spurting blood. The client subsequently dies. Which legal concept applies to the PN's actions?
A. Good Samaritan. Correct
BB. 46.ID: 14033298029
A client with a forearm laceration arrives in the clinic applying direct pressure with a clean washcloth. The practical nurse (PN) notes that the washcloth is saturated with blood. What action should the PN implement?
A. Apply digital pressure to arm above the injury. Correct
CC. 47.ID: 14033298057
The practical nurse (PN) is caring for an older client who is receiving oxygen 4 L per nasal cannula. Which finding indicates a therapeutic response?
A. Client oriented to time and place. Correct
DD.48.ID: 14033298041
The practical nurse (PN) is reviewing the electronic medication administration record (MAR) for a client who receives warfarin (Coumadin) daily. A notation on the MAR for yesterday is marked "hold" for the daily Coumadin dose and no other directions are noted for today's dose. What action should the PN take?
A. Check the prescription. Correct
EE. 49.ID: 14033298021
An older client arrives at the outpatient clinic complaining of burning and severe right-sided "chest pain." The practical nurse (PN) observes vesicular eruptions in a line across the anterior and posterior chest wall. What action should the PN implement?
A. Wear gloves during palpation. Correct
FF. 50.ID: 14033297153
Which intervention should the practical nurse (PN) implement for a client who is scheduled for a lumbar puncture?
A. Ensure the client's bed is positioned flat. Correct
GG.51.ID: 14033297167
The practical nurse (PN) is reviewing the schedule of yearly inservice programs for competency-based nursing care. Which criteria should the PN use in selecting programs that provide the best content to maintain nursing competency?
A. Complex procedures that are done only a few times a month. Correct
HH.52.ID: 14033297101
Which finding should the practical nurse (PN) report to the healthcare provider prior to administering as IV infusion with added potassium chloride (KCL)?
A. Urine output of 120 ml in 8 hours. Correct
II. 53.ID: 14033297159
A client who is three days postoperative complains of having "really bad pain" and wants medication now. What action should the practical nurse (PN) implement?
A. Determine the location of the pain. Correct
JJ. 54.ID: 14033297157
The healthcare provider prescribes an immediate transfer to the intensive care unit (ICU) for a client who has become unstable. Which action is most important for the practical nurse (PN) to implement?
A. Provide an SBAR report of the client's status to the charge nurse. Correct
KK.55.ID: 14033298005
The practical nurse (PN) is preparing to transfer a male client from the telemetry unit to an unmonitored medical-surgical unit. Which action should the PN take first?
A. Give report to receiving nurse. Correct
LL. 56.ID: 14033297181
A client who is two days postoperative for a colectomy and temporary colostomy tells the practical nurse (PN) that the drainage bag is full of gas. What action should the PN take?
A. Open the bag's clamp to release the flatus. Correct
MM. 57.ID: 14033298039
The practical nurse (PN) identifies four assigned clients that need additional follow-up care. Which client issue has the highest priority?
A. Infiltrated intravenous secondary medication. Correct
NN.58.ID: 14033297105
A client who had abdominal surgery yesterday is receiving morphine via a patient-controlled analgesia (PCA) infusion pump. The client reports a pain level of 6 based on a pain scale of 1 to 10. What action should the practical nurse (PN) implement first?
A. Ask for a description of the pain. Correct
OO.59.ID: 14033296499
The practical nurse (PN) is administering medications to several clients. Which client requires immediate action by the PN?
A. A male client who states that his throat feels tight. Correct
PP. 60.ID: 14033298027
A client who is demonstrating violent behavior is restrained by personnel using a 4-man maneuver. Two days later, the practical nurse (PN) sees that the client's arm is ecchymotic and mottled. What finding is most important for the PN to document?
A. Radial pulse. Correct
QQ.61.ID: 14033297147
Which factors influence how the practical nurse (PN) obtains vital signs on a client? (Select all that apply.)
A. Client height 5 feet 6 inches, weight 240 pounds (109 kg). Correct
B. History of right radical mastectomy two years ago. Correct
C. Daily use of oral digoxin (Lanoxin). Correct
RR. 62.ID: 14033298043
Which action should the practical nurse (PN) take for a client whose serum sodium level is 159 mEq/L?
A. Encourage fluid intake of 2500 ml daily. Correct
SS. 63.ID: 14033298061
The practical nurse (PN) is assessing a client and obtains a pulse rate of 120 beats/minute, respirations of 28 breaths/minute, and a blood pressure of 80/60. Which action should the PN take first?
A. Position the client flat in the bed. Correct
TT. 64.ID: 14033298003
A client who is postoperative is receiving an infusion at 80 ml/hour. At the end of 8 postoperative hours, the practical nurse (PN) documents that the client tolerated 100 ml oral intake of ice chips, and urinary output is 1,100 ml. What action should the PN take?
A. Document the intake and output findings. Correct
UU.65.ID: 14033297151
The practical nurse (PN) is working with a newly employed PN who is having difficulty preparing the infusion pump for administration of an IV medication per secondary infusion. What action should the PN implement?
A. Demonstrate the use of the IV infusion pump. Correct
VV. 66.ID: 14033297171
The wife of an older, overweight man tells the practical nurse (PN) that her husband snores and frequently wakes up jerking or gasping. What action should the PN take?
A. Discuss the possibility of a sleep study for sleep apnea. Correct
WW. 67.ID: 14033296495
A client is receiving supplemental oxygen. The practical nurse (PN) walks in the room and sees a fire in the bedside wastebasket. Which action should the PN take first?
Take client out of room. Correct
XX.68.ID: 14033298047
Which client needs immediate action by the practical nurse (PN)?
A. An older client who is climbing over the side rails. Correct
Awarded 1.0 points out of 1.0 possible points.
YY. 69.ID: 14033298035
A client who is 8 hours postoperative begins using the incentive spirometer (IS) with 750 ml inspiratory volume and coughs up a large, thick, light yellow-white mucous plug. Which action should the practical nurse (PN) take?
Document the findings. Correct
ZZ. 70.ID: 14033297173
The healthcare provider calls the nurses' station to give telephone call prescriptions for a client who is recently admitted to the unit. The practical nurse (PN) is unsure of the prescription given by the healthcare provider.
Which action should the PN take?
A. Read back the prescription to the healthcare provider. Correct
AAA. 71.ID: 14033297161
Which disposable product should the practical nurse place in a biohazard container?
A. Peri-pads saturated with rubra lochia for a client who is one day post-vaginal delivery. Correct
BBB. 72.ID: 14033297175
A client has an automatic blood pressure cuff on the right arm where an intravenous (IV) is infusing. In the left arm, a saline lock is present. The practical nurse (PN) notes the presence of blood in the IV infusion line. What action should the PN implement?
A. Move the blood pressure cuff to the left arm. CCC. 73.ID: 14033296487
A client with a possible mumps infection is admitted to an acute care facility. Which infection control precaution should the practical nurse (PN) implement?
A. Wear a mask or respirator within 3 feet of the client. DDD. 74.ID: 14033297163
At 0900, a client's blood pressure is 120/70. At noon, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 200/100. Which action should the practical nurse (PN) implement first?
A. Take client's blood pressure. Correct
EEE. 75.ID: 14033297193
Which action by another nurse should the practical nurse (PN) report as a breach of client confidentiality?
A. Visitors are told to wear a mask because the client has tuberculosis. Correct
FFF. 76.ID: 14033296491
The practical nurse (PN) is caring for a male client who wears a hearing aide. Which client behavior should the PN identify that indicates further evaluation of the client's ability to hear?
A. Does not respond when his name is called from behind. Correct
GGG. 77.ID: 14033297185
Which finding indicates to the practical nurse that the client is meeting the rehabilitation goals after an acute brain attack?
A. Puts hands on chair arms when standing to use a walker. Correct
HHH. 78.ID: 14033297195
Which equipment malfunction should the practical nurse (PN) report as having the highest risk to client safety?
A. Intravenous pump screen does not light up when turned on. Correct
III. 79.ID: 14033296497
Which technique is most important for the practical nurse to implement when obtaining a specimen for urinalysis, culture, and sensitivity for a male client?
A. Ensure client understands to retract the foreskin and cleanse meatus. Correct
JJJ. 80.ID: 14033298051
The practical nurse (PN) is checking client care equipment in the clinic for proper functionality. Which finding should the PN identify as a piece of equipment in need of repair?
A. Intravenous pump alarms constantly. Correct [Show Less]