HESI VN/ PN EXIT Exam 2022/ 2023
1. When obtaining a capillary blood sample for glucose measurement, which intervention should the practical nurse (PN)
... [Show More] implement?
a. Grasp the subcutaneous tissue and pull upward
b. Remove any nail polish from the fingernails
c. Determine which finger was used previously
d. Apply a tourniquet above the antecubital fossa
Rationale: Using another site than a previously accessed finger pad reduces repeated trauma to the tissue and capillary supply in the distal finger where the blood sample is taken.
2. The practical nurse (PN) is assisting a client to cough and deep breathe following surgery. To facilitate effective coughing, the PN should assist the client to assume which position?
a. Lying prone with the head turned to one side
b. Leaning forward over the bedside table
c. Left-lateral with pillow between flexed knees
d. Sitting on the side of bed with feet flat on the floor
Rationale: Sitting upright facilitates diaphragm excursion and enhances thoracic and abdominal expansion.
3. An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?
a. Remind the client what day of the week it is
b. Document the client’s loss of memory in the record
c. Notify the family of the changes in the client’s condition
d. Encourage the client to rest during the day
Rationale: Relocation often results in confusion among elderly clients during times of adjustment to new surroundings. The PN should remind the client which day of the week it is when she forgets or becomes confused. The other actions are not indicated at this time for relocation or stress.
4. The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?
a. Frequency of bowel movements
b. Blood pressure while standing
c. Ability to swallow
d. Urinary output
Rationale: Stomatitis or inflammation of the oral mucosa can cause pain and result in difficulty in swallowing. The PN should gather information related to the client’s ability to swallow. [Show Less]