A male client who is admitted the morning of his scheduled surgery tells the pn that he
drank a glass of water last night. What interventions will the PN
... [Show More] implement first?
a Reassure the client that a small amount of water is not harmful
b Determine the amount of water and exact time it was taken
c Auscultate the client for bowel and ability to urinate
d Notify the healthcare provider of the client's fluid intake
b Determine the amount of water and exact time it was taken
The client receives ondansetron prior to chemotherapy therapy. How should the PN
evaluate medication?
a Determine if the client feels calm and relaxed before treatment
b Observe the client for signs of pain and discomfort during the treatment
c Monitor the client for nausea/ vomiting following the treatment
d Assess for changes in vital signs during and after treatment
c Monitor the client for nausea/ vomiting following the treatment
During morning rounds a client who is admitted with obsessive compulsive disorder is in
the same table. What interventions should the PN implement when approaching?
a Encourage the client to be calm and relax for a little while
b Assist the client to identify stimuli that precipitates the activity
c Provide time for the behavior then guide the client to other activities
d Assist the client to a chair after taking away the cleaning materials
c Provide time for the behavior then guide the client to other activities
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?
a Refuses to use a walker when ambulating
b Likes to drink several cola drinks every day
c No recorded bowel movement for several days
HESI PN EXIT EXAM TEST BANK 2020/2021 V1 Latest Grade A (Gold Rated )
d Has increasing episodes of urinary incontinence
d Has increasing episodes of urinary incontinence
The PN determines that a client with cirrhosis is experiencing peripheral take?
a Apply a heating pad to affected area
b Assess the feet and legs for jaundice
c Keep the clients feet elevated
d Protect the client's feet from injury
d Protect the client's feet from injury
A client is admitted to the postoperative surgical unit after a left lobectomy with two
chest observes that the water sealed chambers set at the prescribed suction of 20 cm
water and bubbling. What action should the PN implement?
a Notify the RN of the malfunction
b Apply a partial occlusive dressing to chest
c Clamp the chest tube to see if activity stops
d Maintain system integrity to promote lung reexpansion
d Maintain system integrity to promote lung reexpansion
At the end of a 12 hour shift the PN observes the urine in a clients drainage action should
PN take next?
a Determine if the clients bladder feels distended
b Offer to administer a prescribed PRN analgesic
c Note the most recent WBC
d Obtain a fingerstick capillary glucose level
c Note the most recent WBC
A client with a compound fracture of the left ankle is being discharged with a below PN
provide to the client prior to discharge?
a Keep the left leg in a dependent position
b Expect some increase in pain
c Never scratch under the cast
d Apply a cold pack to any hot spots on the cast
c Never scratch under the cast
Thirty minutes after receiving IV morphine, a postoperative male client continues to rate
action should PN implement first?
a Call healthcare provider to request a different analgesic
b Observe dressing to determine presence of bleeding
c Determine when morphine can be given again
d Implement complementary pain relief methods
d Implement complementary pain relief methods
A male client who has been diagnosed with schizophrenia withdrawn, isolates himself in
with one or two word responses. This morning , the PN observes that he. Which
intervention is most important for the PN to implement?
a Observe the client during the shift
b Persuade the client to lie down
c Provide a drink high in electrolytes
d Measure appropriate vital signs
d Measure appropriate vital signs
The PN is assisting an unsteady client to ambulate from the bed to the ba client loses
balance and falls into the beside table. What actions should the PN take first?
a Stay with the client and call for assistance
b Assist the client back to bed
c Take the client vital signs
d Reassure the client that everything will be okay
a Stay with the client and call for assistance
The PN is assisting a female client to obtain a voided specimen for urine meatus, which
intervention is performed next?
a Separate the labia
b Position the collection cup
c Observe the urine
d Initiate the urine stream
d Initiate the urine stream
An 8 year old is placed in 90-90 traction for a fractured femur that resulted from further
action by the PN?
a Child moves the toes freely when tickled
b Weights are touching the foot of the bed
c Mother helps child change positions
d No bowel movement for two days
d No bowel movement for two days
The PN is reviewing diet instruction with a female client who has hyper she has
increased her intake of protein and calories. What action should the PN take?
a Reinforce with her the need to also increase intake of dietary fiber
b Remind the client to increase physical activity to prevent weight gain
c Emphasize the need to reduce caloric intake, rather that increasing it
d Encourage the client to continue the dietary changes she has made
d Encourage the client to continue the dietary changes she has made
A 3 year old child returns to the pediatricians' office for a postoperative visit after having
a procedure. The PN should expect to observe which behavior?
a Plays doctor and nurse with dolls
b Points to the nose and says nose
c Cuts out and pastes pictures
d Plays a board game with another child
a Plays doctor and nurse with dolls
The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis
and is preparing for discharge from the hospital. What... select all that apply
a Fluid intake needs to be the same amount every day
b Why the fluid measurements need to be recorded
c The importance of recording output every hour
d Which food types are included when measuring fluid intake
e What container to use for the most accurate measurement
b c d
A male client receives a prescription for 3,000 mg of medication daily, which is
available...taken twice daily in equal dosages.How many tablets should the PN…
3
before her menstrual period. the PN determines the client is not pregnant... of days. what
action should PN take?
a suggest that client schedule a mammogram after her next menstrual period
b explain to the client that an ultrasound of the breast will most likely be necessary
c request return visit for examination after her period when hormones are lowest
d assure the client that her breasts are normal, and advise annual examinations
c
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?
a The 6-year old son hits his younger sister during the interview
b The adolescent daughter rolls her eyes at her mother's comment
c The 10-year old daughter has circular burns on her trunk and legs
d The 3-year old has multiple bruises on the chest and both legs
e The 3 month old is crying because the mother says it is feeding time
acd
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
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?
a Daily weight
b Bowel sounds
c Gastric residual volumes
d Urinary and stool output
c
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?
a Check for engorgement and check the nipples for cracks or lesions
b Ensure that all the areolar tissue of the nipple is in the infant mouth
c Have the mother reposition the infant from the cradle to the football hold
d Apply an ice pack to the breast for 10 minutes before each feeding
b
Which site should the PN use when administering an injection of Rho (D) Immune
negative postpartum client?
a Rectus abdominis
b Dorsogluteal
c Deltoid
d Vastus lateralis
c
Before inserting medication into a clients vagina, what instructions should the pn...
a Place feet in stirrups
b Urinate until bladder is empty
c Bear down during insertion
d Contract pelvic muscles
b
a 18 year old female client with pelvic inflammatory disease asks the PN "how...." which
information is the best for PN to provide?
a a history of untreated gonorrhea can lead to PID
b PID is related to a flare-up of genital warts
c there is no known cause attributed to PID
d PID can result from inadequate perineal cleansing
a
A 28-year old client is in active labor and complains of a cramp in her leg. What
intervention should the PN implement?
a Massage the calf and foot
b Extend the leg and flex the food
c Check the pedal pulse in the affected leg
d Elevate the leg above the heart
b
A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most
effectively deal with breast engorgement and discomfort?
a Take acetaminophen as needed
b Wear a supportive bra at all times
c Apply a heating pad to the breasts
d Manually express breast milk
b
A client with schizophrenia reports auditory hallucinations when admitted to the hospital.
PN to include in the assessment of this client?
a When are the voices most disturbing
b How do you cope with the voices
c What are the voices uttering?
d Which medication works best
c
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?
a Self actualization
b Purposefulness
c Intimacy versus isolation
d Altruism
a
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?
a Tell the client to rise carefully when standing from a sitting or lying position
b Explain the risks associated with using herbs instead of prescribed antihypertensive
c Keep a log of blood pressure measurements taken at the same time each day
d Inform client that herbal supplements can interact with prescribed antihypertensive
b
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 ?
a Report the client's feeling of culture shock to the health care provider
b Act as the client's advocate when discussing the issue with the health care provider
c Consult with a native american healer regarding proper use of the medicine wheel
d Teach the client the importance of implementing the prescribed chemotherapy regimen
b
The PN is caring for a client receiving chemotherapy who has
thrombocytopenia..important to include in the nursing care plan?
a Maintain protective isolation precautions
b Obtain the client's blood pressure frequently
c Observe the signs of dehydration
d Watch the client for abnormal bleeding
d
A male client takes one baby aspirin daily to prevent heart attack. He asks the practical
nurse... administer to his visiting eight year old grandchild who has developed a fever
and sore...PN?
a You can safely use children's aspirin as long as you check the dose on the label correctly
b Be sure to give the med with some crackers or milk to reduce stomach upset
c Giving a prescribed med to anyone else, whether a child or adult, is not safe practice
d It is better to obtain children's acetaminophen to prevent possible side effects from the aspirin
d
A client is transferred to the surgical unit from the intensive care unit after evacuation of
bilateral..primary observation should the PN monitor?
a Fever related to pneumonia or urinary tract infection
b Intake and output related to fluid related to fluid retention or overload
c Homan's sign related to immobility and thrombophlebitis
d Neuro vital signs related to bleeding and intracranial pressure
d
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 shift?
a Assess the pain level of each client and provide comfort measures as indicated
b Total the clients PO intake, fill the water pitchers, empty urinals and catheter bags
c Mark NG tube suction canisters and empty wound drainage collection units
d Assist two postoperative clients on the unit to ambulate in the hallway
b
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..?
a Recent urine drug screen report
b Screening for tardive dyskinesia
c Prescription for lorazepam
d History of parkinson's disease [Show Less]