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
... [Show More] intervention 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 A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses.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]