HESI PN LPN Fundamentals Exam (100 out of 100) Actual Exam GRADED A) A client who is in hospice care complains of increasing amounts of pain. The
... [Show More] healthcare provider prescribes an analgesic every f our hours as needed. Which action should the LPN/LVN implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. A. Give an around-the-clock schedule for administration of analgesics. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand arel/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider C. Infuse 10 percent dextrose and water at 54 ml/hr. When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet. B. Upper torso. In developing a plan of care for a client with dementia, the LPN/LVN should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep. B. often follows relocation to new surroundings. An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine. B. Fowler's. The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. B. Continue asking the mother questions about the child. When conducting an admission assessment, the LPN should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices. C. Many complimentary healing practices can be used in conjunction with conventional practices. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors B. Nutritional history. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours D 72 to 96 hours A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? 20 mg x (5mL/12.5mg) = 8 mL A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? 80 mg x 20 kg = 1,600 1,600/4 x day (q6h) = 400 mg A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Label the pump with a defective equipment sticker. b. Unplug the pump. c. Obtain a replacement pump. d. Notified the biomedical department to fix the pump. b. Unplug the pump. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? a. Hold the suction catheter with the clean non-dominant hand. b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum. c. Place the catheter in a location that is clean and dry for later use new line. d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing . d. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing . - NEVER EVER REUSE THE SUCTION CATHETER A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? a. Supine and low-Fowler's position b. Right lateral in Trendelenburg position c. Side lying with the right side of the chest elevated d. Prone with pillows under the extremities b. Right lateral in Trendelenburg position A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify? a. Dietitian consult b. Speech therapy referral c. Oral suction at the bedside d. Clear liquids d. Clear liquids- liquids must be THICK. Clear liquids can cause aspiration. A nurse is providing teaching to a client who has a new med prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? a. Ptosis b. Hematuria c. Urticaria d. Nausea c. Urticaria A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood glucose test. Which of hte following instructions should the nurse include in the teaching? a. Don sterile gloves prior to puncturing the site b. Puncture site after cleansing and before antiseptic dries. c. Gently squeeze the puncture site until a large droplet of blood forms d. Hold the finger to puncture above the level of the heart c. Gently squeeze the puncture site until a large droplet of blood forms A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures . b. I will hold my breath when rising from a sitting position c. I will remove my antiembolic stockings while I am in bed d. I will have my partner help me change positions every 4 hours a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures . A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the nurse include when developing the plan of care? a. The Hispanic culture views late adulthood as a negative time in the client's life b. The Hispanic culture identifies the eldest female family member as the decision maker c. The Hispanic culture expects individuals to make their own decisions when death is imminent. d. The Hispanic culture expects adult children to care for older adult parents. b. The Hispanic culture identifies the eldest female family member as the decision maker A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take? a.) Perform deep palpation at the end of the admission assessment b.) Auscultate the client's abdomen before palpation c.) Begin palpation of the abdomen at the site of pain d.) Assess the client's bowel sounds using the bell of the stethoscope b.) Auscultate the client's abdomen before palpation A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water while attempting to void b.) Provide the client a bedpan while lying supine c.) Insert an indwelling urinary catheter and connect it to gravity drainage d.) Encourage fluid intake up to 1,000 mL daily a.) Allow the client to hear running water while attempting to void A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select ALL) a.) "I need to set my hot water heater to 140 degrees Fahrenheit" b.) "I will use the grab bars when getting in and out of the bathtub" c.) "I will apply tape over frayed areas of electrical cords" d.) "I need to have a fire escape plan with my family" e.) "I need to check my medications for expiration dates" b.) "I will use the grab bars when getting in and out of the bathtub" d.) "I need to have a fire escape plan with my family" e.) "I need to check my medications for expiration dates" A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a.) "I should roll the NPH vial between my hands before drawing it up" b.) "I should draw up the NPH insulin before the regular insulin" c.) "I should inject air into the vial of regular insulin first" d.) "I should wait 10 minutes after mixing the insulin to inject it" a.) "I should roll the NPH vial between my hands before drawing it up" A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider? a.) Place the client in a room away from the nurses‟ station b.) Limit the client's visitors c.) Give the client washcloths to fold d.) Close the door of the client's room c.) Give the client washcloths to fold A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report? a.) Where the client ate his breakfast b.) The times for routine vital sign measurements c.) The exact times the client had visitors d.) The type of transmission-based precautions in place d.) The during a mass casualty event. Which of the following clients is the nurse‟s priority? a. A client who received crush injuries to the chest and abdomen and is expected to die. b. A client who has a 4-inch laceration to the head. c. A client who has partial-thickness and full-thickness burns to his face, neck and chest. d. A client who has a fractured fibula and tibia. c. A client who has partial-thickness and full-thickness burns to his face, neck and chest A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) a. Open doors to client rooms. b. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. Draw shades and close drapes. e. Instruct ambulatory clients in the hallways to return to their rooms. b. Place blankets over clients who are confined to beds. c. Move beds away from the windows. d. Draw shades and close drapes. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. Irrigate the affected area with running water. b. Wash the affected area with antibacterial soap. c. Brush the chemical off the skin and clothing. d. Leave the clothing in place until emergency personnel arrive. c. Brush the chemical off the skin and clothing. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? a. Give the client information about immunization against meningitis. b. Tell the client to have a TB skin test every 2 years. c. Determine the client's health risks. d. Teach the client about exercise recommendations. c. Determine the client's health risks. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) a. Help the client see the benefits of their actions. b. Identify the client‟s support systems. c. Suggest and recommend community resources. d. Devise and set goals for the client. e. Teach stress management strategies. a. Help the client see the benefits of their actions. b. Identify the client‟s support systems. c. Suggest and recommend community resources. e. Teach stress management strategies. A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? a. The client is able to discuss the appropriate technique. b. The client is able to demonstrate the appropriate technique. c. The client states an understanding of the process. d. The client is able to write the steps on a piece of paper. b. The client is able to demonstrate the appropriate technique. A nurse in a provider‟s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? a. Cognitive b. Affective c. Psychomotor d. Kinesthetic b. Affective A nurse is giving a presentation about accident to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) a. Store toxic agents in locked cabinets. b. Keep toilet seats up. c. Turn pot handles toward the back of the stove. d. Place safety gates across stairways. e. Make sure balloons are fully inflated. a. Store toxic agents in locked cabinets. c. Turn pot handles toward the back of the stove. d. Place safety gates across stairways. A nurse is counselling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? a. "I spent my whole life dreaming about retirement, and now I wish I had my job back." b. "It‟s been so stressful for me to have to depend on my child to help around the house." c. "I just heard my friend Al died. That's the third one in 3 months." d. "I keep forgetting which medications I have taken during the day." d. "I keep forgetting which medications I have taken during the day." A nurse is collecting data for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skill of the physical examination process should the nurse perform next? a. Olfaction b. Auscultation c. Palpation d. Percussion b. Auscultation A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse is 84/min. what is the client's pulse deficit (per minutes)? 16 A nurse in a provider‟s office is preparing to assess a client‟s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Capillary refill less than 3 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet e. Numerous macules on the face darker than the surrounding skin color a. Capillary refill less than 3 seconds d. Thick skin on the soles of the feet e. Numerous macules on the face darker than the surrounding skin color A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? 0.3mL A nurse is preparing to administer lactated Ringer‟s (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? 400mL/hr A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? 83 gtt/min A nurse is preparing to administer metoprolol 200-mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? 2 tablets A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30-mg/mL. How many mL should the nurse administer per dose? 0.5 mL A nur [Show Less]