HESI Practical Nurse Fundamentals | Full Exam Q&A | Latest 2026–2027 | Verified Answers with Rationales | 100% Correct solutions

HESI Practical Nurse Fundamentals | Full Exam Q&A | Latest 2026–2027 | Verified Answers with Rationales | 100% Correct solutions Q: The nurse is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? A. Cyanosis in a client with dark skin is seen in the sclera B. Abnormal skin color changes in a client with dark skin cannot be determined C. The lips and mucus membranes of a client with dark skin are dusky in color D. Blanching the soles of the feet in a client with dark skin reveals cyanosis C. The lips and mucus membranes of a client with dark skin are dusky in color Q: Which technique should the PN use to most accurately assess a client's baseline BP during a routine health exam? A. Measure the pressure in each arm while the client sits with both arms supported at heart level B. Calculate avg BP using readings obtained in both arms C. Obtain BP first with client lying supine and then when standing D. Take additional measurements for readings with a 10 mm Hg difference A. Measure the pressure in each arm while the client sits with both arms supported at heart level Q: A client with gastroenteritis, nausea, and vomiting is currently on Nothing by mouth (NPO) status. The healthcare provider prescribes oral intake to be advanced as tolerated. Which fluid should the practical nurse offer first? A. Tea B. Broth C. Water D. Soda C. Water Q: An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy for the practical nurse (PN) to implement for the client's incontinence? A. Insert an indwelling urinary catheter B. Apply absorbent incontinence pads C. Restrict fluids after the evening meal D. Establish a 2-hour voiding schedule D. Establish a 2-hour voiding schedule Q: Which intervention should the practical nurse (PN) implement to reduce the incidence of urinary tract infections in a client with an indwelling catheter? A. Irrigate cath with sterile distilled water B. Dilute an antiseptic solution in the perineal wash C. Cleanse perineal area with soap and water BID and PRN D. Apply an antibiotic ointment around urinary meatus BID C. Cleanse perineal area with soap and water BID and PRN Q: A male client is upset with the healthcare provider's recommendation that he should consent to an above-knee amputation. He tells the practical nurse (PN), if they want to cut off my leg, they should just shoot me instead. How should the PN respond? A. Ask the client how the surgery might effect his lifestyle B. Offer to stay with the client wile he makes his decision C. Express sympathy that there is no other choice possible D. Explain how many others function well with a prosthesis A. Ask the client how the surgery might effect his lifestyle Q: A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. he client expresses fear about becoming addicted to these drugs. What information should the practical nurse (PN) provide? A. Opioid use with cancer does not cause addiction B. Addiction is easily reversed if it occurs during pain management C. Prescribed opiates for cancer pain relief improves quality of life D. Opiate dosages can be tapered is a client fears addiction C. Prescribed opiates for cancer pain relief improves quality of life Q: Which intervention should the practical nurse (PN) implement to help a client cope effectively with chronic pain? A. Administer around the clock opiate drugs B. Give scheduled doses of benzodiazapines C. Recommend avoiding painful activities D. Encourage using relaxation techniques D. Encourage using relaxation techniques Q: A young woman, who is the primary caregiver for her mother who has Alzheimer's disease, tells the practical nurse (PN), "Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." What response should the PN offer? A. What you do to cope with these feelings? B. Have you told your family how you feel? C. It's normal feel these emotions when you are stressed. D. Don't worry, at least you can talk about your angry. A. What you do to cope with these feelings? Q: A male Native American client with tuberculosis is visiting a health care clinic for follow up treatment. During the interview, the practical nurse (PN) notices that the client keeps his eyes on the floor and does not make eye contact. How should the PN interpret this client's behavior? A. He is uncomfortable with violation of his personal space B. The client is depressed and concerned about his diagnosis C. His culture finds sustained eye contact rude and disrespectful D. The client is reluctant to speak without a tribal shaman there C. His culture finds sustained eye contact rude and disrespectful Q: The practical nurse (PN) is caring for a client who is admitted with influenza and vomiting for 3 days. The client's skin turgor is poor and oral mucous membranes are dry. Which finding is most important for the practical nurse (PN) to report to the charge nurse? A. Weight loss of 4lbs in the last 3 days B. Hypotension and tachycardia C. Nausea and anorexia D. Dark amber urine output at 30mL/hour B. Hypotension and tachycardia Q: The practical nurse (PN) is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client? A. Soybeans. B. Peanuts. C. Whole wheat. D. Sesame seeds. A. Soybeans Q: The client is receiving a continuous tube feeding. While checking the gastric residual volume, the practical nurse (PN) aspirates 150 mL of gastric contents. What action should the PN take? A. Rinse the feeding tube after throwing away the aspirated gastric contents and restart the feeding B. Replace half of the aspirated gastric contents and slow the rate of feeding C. Throw the aspirated gastric contents away and stop the continuous feeding D. Return all the aspirated contents to the stomach followed with water and consult agency policy D. Return all the aspirated contents to the stomach followed with water and consult agency policy Q: During insertion of a nasogastric tube (NGT) into the right nares, the client starts to cough. Which action should the practical nurse (PN) implement? A. Notify the HCP and report the inability to insert the NGT B. flush NGT with 30mL of tap water to check for patency C. Withdraw NGT to oral pharynx, reposition client's head, and reinsert D. Continue placing NGT because coughing is an expected response C. Withdraw NGT to oral pharynx, reposition client's head, and reinsert Q: The practical nurse (PN) observes a client who begins to choke during a meal. determining that the client cannot speak, what action should the PN implement? A. Initiate CPR B. Administer 4 upward abdominal thrusts C. Sweep airway with a hooked index finger D. Place a fist halfway b/w xiphoid process and umbilicus D. Place a fist halfway b/w xiphoid process and umbilicus Q: An older male client who is incontinent receives a prescription for a condom catheter. Which step(s) should the practical nurse implement when applying the external catheter? (select all that apply) A.Wrap the adhesive strip in a spiral around the penis. B. Shave perineal areas before beginning C. Apply skin prep to the penile shaft and allow to dry. D. Leave 1 to 2 inches between the tip of the penis and condom catheter. A.Wrap the adhesive strip in a spiral around the penis. C.Apply skin prep to the penile shaft and allow to dry. D. Leave 1 to 2 inches between the tip of the penis and condom catheter. Q: The practical nurse (PN) is irrigation a client's indwelling urinary catheter, After injection normal saline as prescribed, what action should the PN implement? A. Massage client's bladder for 30-45 sec B. Keep tubing clamped for 30-45 min C. Unclamp tubing and lower collection bag D. Ask client to take deep breath and hold it C. Unclamp tubing and lower collection bag Q: A client's indwelling urinary catheter is removed at 9:30 AM. The practical nurse (PN) assesses the client every two hours for the desire to void. Which documented assessment requires further intervention by the PN? A. 1:30 pm - unable to void B. 5:30 pm - unable to void C. 3:30 pm - unable to void D. 11:30 am - unable to void B. 5:30 pm: unable to void. Q: The healthcare provider prescribes a cleansing enema for an adult prior to bowel surgery. Which intervention(s) should the practical nurse implement to ensure adequate bowel cleansing? (Select all that apply) A. Place the client on the left side in Sim's position. B. Use enema fluid that is near 105 F (40.4 C). C. Repeat enemas until expelled fluid is clear D. Instill 500 mL to 1,000 mL fluids slowly. E. Raise the enema container 20 inches above anus. F. Encourage the client to retain fluid 10 to 15 minutes. A. Place the client on the left side in Sim's position. B. Use enema fluid that is near 105 F (40.4 C). D. Instill 500 mL to 1,000 mL fluids slowly. E. Raise the enema container 20 inches above anus. F. Encourage the client to retain fluid 10 to 15 minutes. Q: Which position is best for the practical nurse to place the client during administration of a rectal suppository for constipation? A. Prone with pillows under abd B. Supine with client on bedpan C. Left Sims' with upper leg flexed D. Right side-lying knee-chest position C. Left Sims' with upper leg flexed Q: The practical nurse (PN) is adding tap water to several medications for administration via feeding tube. Which preparation should the PN administer without delay? A. Reconstituted powder. B. Timed release capsule. C. Cherry flavored elixir. D. Flavorless suspension. B. Time released capsule. Q: Which action should the practical nurse (PN) take when drawing medication from an ampule? A. Aspirate with a filter needle and syringe B. Tap bottom of ampule lightly C. Snap neck of ampule towards nurse D. Use alcohol swab to open ampule A. Aspirate with a filter needle and syringe Q: The practical nurse (PN) is preparing to reconstitute a drug from powder for for IM administration. Which step should the PN implement first? A. Verify the drug with the medication administration record (MAR). B. Mix powder with the solution C. Attach needle to syringe D. Read label to determine amount of dilutent to use A. Verify the drug with the medication administration record (MAR) Q: Which action should the practical nurse (PN) implement when administering a subcutaneous injection to a client who weighs 325 pounds? A. Produce a bleb at injection site B. Insert needle at 15 degree angle C. Select a needle with a longer shaft. D. Rub vigorously for faster response C. Select a needle with a longer shaft Q: Which finding indicates to the practical nurse (PN) that an older client who is receiving intravenous therapy is experiencing fluid overload? A. Edema in lower extremities B. Crackles in lungs C. Pulse rate of 64 beats/minute D. Respirations of 16 breaths/minute B. Crackles in lungs Q: The practical nurse (PN) is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. what nursing action should the PN take? A. Reinforce dressing with clean gauze sponges and tape B. Change surgical dressing immediately to prevent infection C. Mark the outlined area of drainage with date, time and initials D. Collect a sample of drainage for a culture and sensitivity C. Mark the outlined area of drainage with date, time and initials Q: The male client who is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." which action should the PN implement first? A. Notify HCP B. Assist client to supine position C. Instruct client to avoid deep breathing D. Request abd binder from coworker B. Assist client to supine position Q: The practical nurse (PN) is applying a dry, sterile dressing to a client's abdominal wound. Which allergy should the PN verify with the client? A. Tape B. Antibiotic ointment C. Povidone-iodine D. Hydrogen peroxide A. Tape Q: The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing? A. Pull from left to right across abd B. Peel across abd from right to left C. Start from top of incision moving to bottom D. Remove all four sides by moving to the center of the incision D. Remove all four sides by moving to the center of the incision Q: Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client's leg? A. Secure the end with metal clips. B. Overlap turns of the bandage equally. C. Adjust the tension as needed. D. Wrap from the proximal to distal end. B. Overlap turns of the bandage equally. Q: An older client who has been on bed rest in not eating well and is exhibiting abdominal distension, cramping, and is passing small amounts of liquid stool. Which prescribed action is most important for the practical nurse (PN) to implement? A. Place incontinence pads on bed B. Give PRN dose of stool softener C. Digitally remove a fecal impaction D. Administer soap subs enema C. Digitally remove a fecal impaction Q: Acetaminophen is prescribed for an unconscious client with a temperature of 104° F. Which route should the practical nurse (PN) plan to administer this medication? A. Oral. B. Rectal. C. Buccal. D. Topical. B. The rectal route Q: An older client who complains of dry mouth is having trouble swallowing pills. What action should the practical nurse take when administering an enteric-coated tablet? A. Crush med and minx with cereal B. Place the whole tablet in a spoonful of pudding C. Break pill in half to make it easier to swallow D. Dissolve drug in 4 oz of applesauce B. Place the whole tablet in a spoonful of pudding Q: An older client who is unable to swallow is receiving continuous nasogastric tube (NGT) feeding. Before administering medication through the NGT, what action should the practical nurse (PN) implement? A. Flush the feeding tube with water B. Put client in supine position C. Assess client's ability to swallow D. Prime solution in feeding pump A. Flush the feeding tube with water Q: The practical nurse (PN) is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site? A. 1 inch B. 2 inches C. 5/8 in D. 1 1/2 in A. 1 inch The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers the client his morning blood pressure medication, he refuses to take it. What action should the PN take? A. Mix the crushed meds into his morning oatmeal B. Explain the importance of routine use of antihypertensives C. Tell client that he should not refuse his prescriptions D. Document that the client refused to take his meds B. Explain the importance of routine use of antihypertensives An older female states that the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse (PN) take? A. Double check med with charge nurse B. Give meds b/c client is confused C. Check the written prescription to verify the medication D. Reassure client that the medication is correct C. Check the written prescription to verify the medication While taking an adult's vital signs, the practical nurse (PN) notes an irregular radial pulse, What action should the PN implement to obtain the most accurate assessment? A. Use Doppler for radial pulse while monitoring apical B. Obtain radial pulse again for full minute followed by apical pulse C. Perform an apical-radial pulse assessment with another nurse D. Verify finding by counting apical pulse using stethoscope C. Preform an apical-radial pulse assessment with another nurse The practical nurse (PN) contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints? A. To decrease client's agitation and acting-out behaviors B. To provide an effective way to reduce falls when client is alone C. To protect client and reduce the likelihood of lawsuits D. To ensure the client's safety when the benefits outweigh the risk D. To ensure the client's safety when the benefits outweigh the risk. Which action should the practical nurse (PN) implement when supporting an older client who is afraid of dying? A. Ask the client about his belief of a spiritual life after death B. Provide basic comfort measures to alleviate pain and breathlessness C. Use open-ended questions to encourage the client to share feelings D. Talk about common beliefs that others have expressed about death C. Use open-ended questions to encourage the client to share feelings A family member of a dying client asks the practical nurse (PN) if the client knows the family is at the bedside. The PN explains that which of the five senses persists the longest during the dying process? A. Smell B. Touch C. Vision D. Hearing D. Hearing Which action should the practical nurse (PN) implement to help a male client cope with his fear as he approaches death? A. Tell client that he will soon find peace and comfort B. Encourage family members to cry at client's bedside C. Hold the client's hand and tell him he is not alone D. Explain signs of impending death to client's family C. Hold the client's hand and tell him he is not alone An older client is receiving nasogastric tube (NGT) feedings for several days. Which finding should the PN report to the HCP? A. Soft, formed stools B. Urine output of 2000mL a day C. Abd distention and nausea D. Dried mucus around nasal tube C. Abd distention and nausea The practical nurse (PN) is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the client's comfort? A. Increase oral fluid intake B. Preform oral hygiene frequently C. Swab inside of mouth with petroleum jelly D. Report rate of IV fluid administration B. Preform oral hygiene frequently The practical nurse (PN) is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement? A. Encourage client to massage gums B. Use mouth wash only C. Obtain a soft-bristle brush for the client D. Have client rinse with warm salt water C. Obtain a soft-bristle brush for the client Which time frame should the practical nurse (PN) reposition a client? A. q 4 hours when awake B. Twice per shift C. q 2 hours D. With each client request C. q 2 hours An older male client tells the practical nurse (PN) that his religion does not permit him to bathe daily. How should the PN respond? A. State that the HCP has prescribed a bath today B. Offer the client several choices of times to bathe during the day C. Review the importance of hygienic measures for improved health D. Request that the client clarify his religious beliefs about bathing D. Request that the client clarify his religious beliefs about bathing An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the practical nurse (PN) that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first? A. Provide frequent intake of oral fluids B. Digitally assess for impacted stool C. Give prescribed stool softener D. Administer a mild analgesic B. Digitally assess for impacted stool The practical nurse (PN) is obtaining information for a male client's psychosocial assessment. Which action should the PN implement first? A. Determine the value the client places on his health B. Establish a therapeutic relationship C. Determine is he has abnormal behaviors D. Ask the client to share info about his past B. Establish a therapeutic relationship Which food should the practical nurse (PN) recommend for a client to increase the dietary intake of potassium. A. Corn B. Baked potato C. Popcorn D. Grape juice B. Baked potato An 80 year old male client who has arthritis and is having difficulty walking, tells the practical nurse (PN), "It's awful to be old, It seems as thought every day is a struggle. No one cares about an old person." What is the best response for the PN to provide? A. "It's true. We are a youth-oriented society" B. "Oh, let's not focus on the negative. Tell me something good" C. "It sounds as though you're having a difficult time. Tell me about it" D. "You're still able to get around, and your mind is as sharp as a tack C. "It sounds as though you're having a difficult time. Tell me about it" A client whose diet is low in fiber is at risk for which condition? A. Hip fracture. B. Diarrhea. C. Confusion. D. Colon cancer. D. Colon cancer An older female recently diagnosed with coronary artery disease (CAD) cooks at home using saturated fats, Which intervention should the practical nurse implement to help the client reduce modifiable risk factor(s)? A. Recommend adoption of a low sodium vegetarian diet B. Encourage food preparation with various vegetable oils C. Explain the benefits of a modified exercise program D. Provide pamphlets which outline CAD risk factors B. Encourage food preparation with various vegetable oils Which action by the practical nurse (PN) demonstrates the value of dignity in client care? A. Reviews medications and allergies with charge nurse B. Closes the door and covers the client during a bath C. Uses the client's first name during admission D. Shares concerns about client's condition with family B. Closes the door and covers the client during a bath Which growth and developmental characteristic should the practical nurse (PN) consider when discussing spirituality with an adolescent client? A. Has a good concept of a supreme being. B. Questions religious practices and values. C. Gives oneself to spiritual tasks. D. Accepts the meaning of spiritual faith. B. Questions religious practices and values. The practical nurse (PN) identifies a client's need for spiritual support. What is the first action the PN should take? A. Refer the client to a client advocate or personal chaplain. B. Provide the client with religious literature and references. C. Suggest the client use one's religious faith to cope. D. Determine the client's perceptions and belief system. D. Determine the client's perceptions and belief system. The practical nurse (PN) is obtaining the vital signs for a client who has a urinary tract infection with Methicillin-resistant Staphylococcus Aureus (MRSA). How should the PN proceed? A. Wear exam gloves and use a disposable stethoscope B. Wipe the stethoscope before removing from the room C. Don a gown and gloves before entering the room D. Use a mask and gloves when entering the room C. Don a gown and gloves before entering the room A client is receiving a Mantouz test for tuberculosis screening. Which angle should the practical nurse (PN) insert the needle for injection? A. 15 degrees B. 30 degrees C. 45 degrees D. 90 degrees A. 15 degrees A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client's oxygenation? A. Encourage deep breathing prior to suctioning. B. Increase the oxygen flow rate during suctioning attempts. C. Provide oxygen during rest periods between suctioning. D. Limit suctioning attempts to five second intervals. C. Provide oxygen during rest periods between suctioning. Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status? A. Skin turgor B. Intake and output C. Daily body weight D. Serum electrolyte levels C. Daily body weight Based on The Joint Commission (TJC) standards for pain assessment and treatment, which action is most important for the practical nurse (PN) to implement when assessing a client? A. Use a pain scale to assess all clients for pain when obtaining vital signs. B. Collect objective information about pain to provide the best prescribed treatment. C. Prioritize pain assessment for surgical clients before clients with chronic illness. D. Give prescribed medications to all clients with outward expressions of pain. A. Use a pain scale to assess all clients for pain when obtaining vital signs. Which food should the practical nurse (PN) recommend to a client as a source of complete protein? A. Oats B. Eggs C. Lentils D. Peanuts B. Eggs The practical nurse (PN) identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN? A. Heart rate increase of 10 beats/minute B. Bowel movements decreased to one every third day C. Urinary output decreased to 250 mL in the last 24 hours D. Systolic BP decrease of 10 mm Hg B. Bowel movements decreased to one every third day The practical nurse (PN) is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, and increase in granulation tissue development within two weeks, which intervention should the PN implement? A. Replace dry sterile dressing PRN B. Irrigate wound with normal sterile saline C. Apply heat for 15min three times a day D. Remove heal protector every 2 hours B. Irrigate wound with normal sterile saline In planning care for an older client on bed rest, which intervention should the practical nurse include in the prevention of pressure ulcers? A. Message carefully over each bony prominence B. Elevate the head of the bed less that 30 degrees C. Place client in a lateral position over trochanter D. Use a donut device when placing client in a sitting position B. Elevate the head of the bed less that 30 degrees What position should the practical nurse (PN) place a client in who is receiving an enteral tube feeding? A. Sitting upright B. Lying on side C. Supine with the head of the bed elevated 30 to 45 degrees D. Fowler's with head of bed elevated 45-60 degrees C. Supine with the head of the bed elevated 30 to 45 degrees Following a cholecystectomy, a client asks the practical nurse (PN) about dietary restrictions that may need to be followed. Which diet should the PN recommend? A. Low cholesterol and high carb diet B. Restricted sodium and increased fluid diet C. A well-balanced diet with no other restrictions D. Small, frequent meals to reduce ingestion C. A well-balanced diet with no other restrictions What nutritional information should the PN provide a client with heart failure (HF)? A. Abstain from alcoholic beverages B. Restrict dietary sodium intake C. Maintain a healthy weight D. Exclude dietary saturated fats B. Restrict dietary sodium intake A client is receiving a daily prescription for furosemide (Lasix) 40 mg PO, but is unable to swallow. The practical nurse (PN) should consult with the healthcare provider about which component of the prescription? A. Time of dose B. Prescribed dosage C. The route of administration D. Available generic drug C. The route of administration The practical nurse is administering scheduled morning medications to a client who states, I haven't seen that pill before. Are you sure it's correct? Which action should the PN take? A. Verify the prescription before administrating the medication. B. Withhold the dose to confirm its use with the healthcare provider. C. Reassure the client that the medication is prescribed for a reason. D. Check with the pharmacy to ensure the dispensed medication is correct. A. Verify the prescription before administrating the medication. A client is prescribed a medication that is labeled as a sustained released (SR). What action should the practical nurse (PN) implement when administering this drug form? A. Instruct the client to chew the medication. B. Do not crush or dissolve the tablet or capsule contents. C. Obtain a different drug form for administration. D. Delay giving the medication until the stomach is empty. B. Do not crush or dissolve the tablet or capsule contents. Which information should the practical nurse provide a client who is selecting a site for self injection of insulin? A. Avoid the abd because absorption is irregular B. Choose a different site at random for each injection C. Give the injection in the same area each time to promote consistent absorption D. Rotate sites within the same location for a week before choosing a new location D. Rotate sites within the same location for a week before choosing a new location The practical nurse (PN) hears breath sounds that are short, popping, and discontinuous on inspiration when auscultating a client's lungs. Which description should the PN document in the client's record? A. Wheezes present. B. Crackles auscultated. C. Pleural friction rub noted. D. Bronchovesicular sounds heard. B. Crackles are short Which technique should the practical nurse use to give a Z-tract intramuscular (IM) injection? A. Ensure that no air is present in syringe B. Inject the medication into the dorsal gluteal site C. Select a 22 gauge, 1 inch needle for injection D. Massage site for 2 minutes after injection B. Inject the medication into the dorsal gluteal site When irrigating the eyes of a client, which action should the practical nurse implement? A. Instill the irrigant solution in the center of the eye so it flows out both sides B. Direct the irrigation flow from the inner canthus to the outer canthus of the affected eye C. Massage the irrigation fluid over anterior surface of eye using upper eyelid D. Instruct client to blink repeatedly as irrigant is placed in conjunctiva sac B. Direct the irrigation flow from the inner canthus to the outer canthus of the affected eye When irrigating the external ear canals of an older adult client, which action should the practical nurse (PN) use to soften dry cerumen for removal? A. Heat the container of irrigation solution to body temp B. Instill mineral oil in the external auditory canal overnight before irrigation C. Use a 50 mL syringe to increase force of fluid flow D. Insert wick into auditory orifice for 30 minutes before draining solution B. Instill mineral oil in the external auditory canal overnight before irrigation Which intervention provides confirmation of nasogastric tube (NGT) placement before NGT feedings are started? A. Flat plate xray of the abdomen. B. Auscultation of the abdomen. C. Determining stomach content pH. D. Measuring residual stomach contents. A. An x-ray is the most accurate confirmation method of NGT placement and should be done before formula feedings are initiated. Which intervention should the practical nurse (PN) use to prevent obstruction of a gastric feeding tube? A. Obtain a prescription for a liquid drug form instead of crushing tablets B. Instill an acidic juice, such as cranberry, between intermittent feedings C. Flush the feeding tube with an effervescent cola product to relieve clogs D. Use an asepto syringe to plunge and aspirate the contents of tube A. Obtain a prescription for a liquid drug form instead of crushing tablets A client who has a pressure-relieving mattress overlay is mobilized to a chair and imprints of the clients buttocks, heels, and scapula are evident on the mattress overlay. What action should the practical nurse implement? A. Turn the mattress overlay to the opposite side B. No action is needed b/c this is the mechanism of action for the overlay C. Apply a different pressure relieving device and assess its effectiveness for this client D. Reinforce with cushions b/w the mattress and overlay where the imprints are located C. Apply a different pressure relieving device and assess its effectiveness for this client A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the practical nurse's priority intervention? A. Determine pulse pressure B. Measure pulse-ox C. Assess peripheral pulse points D. Obtain orthostatic blood pressures D. Obtain orthostatic blood pressures The PN turns a client with right sided paralysis from a supine to a left lateral position. which bony prominence is most likely to manifest signs of erythema when first turned? illiac crest One week after beginning a new prescription for potassium chloride. a client tells the PN that there is tingling and numbness in the feet and hands. which action should the PN take? Notify the unit charge nurse of the clients reported symptoms immediately An older adult client with stage one sacral pressure wound is discharged with instructions for home care. which information should the PN reinforce with the client? change positions every 2 hours A client on a prescribed full liquid diet has a nursing problem of " Risk for impaired skin integrity related to reduced oral intake" which snack would be the best to provide this client? A liquid nutritional supplement that contains protein The PN observes a clients mouth and lips as seen in the picture (blocked and looked swollen) which follow up action is most important for the PN to take ? Administer oxygen After accepting employment in a state different from where a practical nurse is currently employed, it is most important for the PN to review which reference? The licensing state's PN scope of practice The unlicensed assistive personnel (UAP) working in a small community hospital obtains 0800 vital sign measurements of clients on the unit. in reviewing these vital signs, which measurement warrants immediate intervention by the PN? A one-month old infant with a heart rate of 80 breaths per minute The client is a 23- year old male who is in the clinic for a well visit. choose the most likely options for the information missing from the statement by selecting from the list of options provided. The cllient is eating a diet with ______ of fat which indicates that the client. 21 top 24%. has an appropriate fat intake for calories While performing a physical assessment on a client with chronic obstructive pulmonary disease (copd) the practical nurse determines that the clients respiratory rate is 30 breaths/minute. when the PN begins to assess the clients range of motion. which is the best plan to implement? Defer ROM assessment because of the respiratory rate The healthcare provider prescribes a continuous delivery of 250ml half strength tube feeding to be infused every 8 hours for a client with a Gastrostomy tube. the PN should program the enteral pump to deliver how many ml/hour? 31 ml/hr The PN is preparing to provide a change of shift report when an oncoming nurse arrives. appearing in toxicated and who describes to another collage about drinking all afternoon and almost forgetting to come to work. which action should the PN take? Inform the charge nurse An older adult client with metastatic lung cancer is experiencing shortness of breath as the result of bilateral pneumonia. the client has previously expressed an interest in hospice care. which information about the PN reinforce with the client family regarding hospice care? select all that applies care can be provided in the house, care focuses on quality of life at the end of life, curative measures are optional To reduce a client's risk for foot drop, which action should the PN implement? begin range of motion exercises The PN calls the healthcare provider to notify them that the heart rate is too low to administer the digoxin. place the nurse statements in situation. background. assessment. recommendation format. I am holding the digoxin because the clients heart rate is too low- situation The client is a 50-year-old male with hypertension and heart failure. he is currently taking furosemide and digoxin- background Do you want to recheck the digoxin level to see if there is toxicity? I will monitor the clients heart rate. blood pressure, perfusion with a continuous monitor until his heart rate returns to normal- recommendation Heart rate is 48 beats/minute. blood pressure is 109/76 mm hg- assessment In providing daily catheter care for a client with a condom catheter. which action should the PN include? Remove the condom and cleanse the penis with soapy water A PN is providing care to a client who recently received a terminal illness diagnosis. which question by the PN is the highest priority when assessing anticipatory grief? Have you had suicidal thoughts? The practical nurse is performing a focused assessment on a client who is experiencing insomnia. The PN should gather additional information about which factor(s) select all that apply effects of sleep loss, bedtime rituals, alcohol consumption, sleep expectations, current life events During vital sign assessment of a client, the PN counts the left radial pulse at 88 beats. minute. and the pulse oximeter clipped to a finger on the left hand records a pulse of 68 beats/minute with an oxygen saturation of 95%. which of the following should the PN do first? Reposition the oximeter clip The PN assigns the UAP the task of transferring an alert client from the bed to the chair. The UAP reports to the PN that the client is confused and cannot bear weight (can't move). Which action should the PN implement? Work with the UAP to use a mechanical left and sling for the transfer The PN plans to administer an IM injection into the mid anterior thigh. which muscle group should be identified as the site of administration? Rectus femoris The PN is caring for a client who is experiencing overwhelming anxiety and difficulty performing self-care. which question should the PN ask first? would you like me to sit with you for awhile A client with malabsorption syndrome has low serum calcium level. the PN should monitor the client for? Tetany The PN is implementing a nursing care plan that requires daily weights. which factor is most important for the PN to consider regarding daily weights? when the client was last weighted An older adult man who manages all his personal affairs is admitted to a long-term care facility because of mobility problems related rheumatoid arthritis. when the PN presents the client with a blank advanced directives form, he explains that he is not dying and not cognitive impaired and informs he does not need to complete such a form. which action is most important for the PN take? Explain that the form identifies his personal health care wishes for any future event The client is a 44-year-old with cerebral palsy who is non-verbal and has severe intellectual development disability. he requires total care at home, which is provided by his two sisters, a home health nurse and a UAP. the client is currently in the hospital for a lower respiratory infection. actions to take : Provide skin care, place indwelling catheter potential condition choices: overflow urinary incontinence parameters to monitor choices: post-void residual, skin integrity The UAP reports to the PN that the bedfast client was not turned during the night. after turning the client, the UAP noted a reddened area on the client's hip. The reddened area lightened when light fingertip pressure was applied by the PN. which action should the PN take? remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown The PN is reviewing laboratory findings for a client with diarrhea for several days. the analysis confirmed that C-diff is present in the client's stool. which comment should the PN provide to family members to avoid the spread of infection? visitors should only wash hands with soap and water while applying sterile gloves (open method) which action should the PN take to ensure that Surgical asepsis is maintained? keep gloved hands in sight above waist level when caring for a client with severe diarrhea. which focused assessment is most important for the PN to complete before reporting to the charge nurse? observe for signs of fluid volume deficit A client who is recently diagnosed with stage 4 ovarian cancer tells the practical nurse that the staff on the unit are insensitive and begins to cry. which intervention(s) should the PN implement? select all that apply show acceptance of the client's current feelings, document the behavior in the client's record, ask the palliative care nurse to see the client, allow the client a time to continue crying. The PN is caring for a client with the flu. which action should the PN implement to prevent the spread of flu? Place a mask on the client if the client leaves the room The PN is assisting with the implementation of an obesity screening program in a pediatric(kids) clinic. it is best to begin the screening program with which group? Elementary school The PN identifies and electrolyte imbalance. an elevated blood pressure and exhibited changes in mental status for a client with acute kidney injury. which intervention in the plan of care should the PN implement? monitor for dependent pitting edema At 2100, an older adult client turns on the call light and reports to the PN the inability to fall asleep. which is the priority nursing action? evaluate the room environment A client is receiving wound care to a laceration on the anterior palm of the right hand. the PN applies a medicated gauze and stabilizes it with the elastic support wrap that encompasses the wrist. which bandaging method should the PN use that will maintain the medicated gauze in place and facilitate movement of the wrist joint? figure-eight turns A male client who was treated for a draining. infected wound and places on contact precautions while hospitalized is being discharged to his home where he lives with his wife and adolescent son. which information should the PN reinforce with the family? place soiled dressings in a plastic bag that can be tightly secured for disposal. When initiating a 24- hour urine collection, which action should the PN take? Instruct the client to discard the first voided specimen A client with fecal incontinence has inflamed skin around the rectal area. following an episode of incontinence. how should the PN care for this area? spray the area with a mild peri wash solution Which disposable product should the PN place in a biohazard container? postop dressing that is saturated with bright red blood The PN is administering an analgesic to a client with low back pain. to promote the effectiveness of the medication. which is the best intervention for the PN to implement? reposition the client with proper alignment and massage the lower back An older adult client is planning a vacation with a group of senior citizens is concerned about developing constipation. the client shares this concern with the PN at the retirement home. which recommendation is best for the PN to provide? increase the daily oral fluid intake The PN is administering multiple medications to an older adult client. the client has been receiving all of the same medications for one week. which assessment is most important for the PN to make? Cumulative effects The PN has been regularly assigned the care of an older adult client who resides in a long-term care facility. when the client is told that they have a terminal illness. which action is best for the PN to take? remain quietly in the clients room for a while When administering belladonna and opium suppositories to a client after a prostatectomy. it is important for the PN to implement which action? Place the suppository high in the rectum The PN is reviewing instructions about the use of Post op analgesia with a client before surgery. the PN should remind the client to ask for pain medication at which time? as soon as the client begins to feel pain Immediately after completing the total bed bath and linen change for an unconscious client, the PN observes that the client was incontinent with a large amount of liquid feces. which actions should the PN implement? Cleanse any soiled skin and change the soiled linens A male client tells the PN that he usually takes a smaller white tablet not the large blue tablet that the PN gives him. which actions should the PN implement first? check the medication's name and strength A 36-year-old male with a 3-day history of fever, cough. has a history of type 1 diabetes melliutus and takes insulin glargine and insulin lispro to manage his diabetes. highlight the times that the PN should measure vital signs? 1000, 1200, 1800,1600,2000,0800 An older adult male client, recently diagnosed with type 2 diabetes refuses to allow the PN to stick his finger to obtain a blood glucose assessment and states " my fingers are sore and its useless anyway. how should the PN document the refusal in the clients EMR" Refused finger stick and states" my finger is sore and test useless." health care provider notified A pre-school age child is admitted with a febrile seizure. the PN obtains an oral temperature of 104.2 F during the morning assessment. which action should the PN prepare to implement? provide a tepid sponge bath While providing oral care for a client who is unconscious. the PN positions the client laterally and uses a basin to collect secretions. which intervention is best for the PN implement? Use oral swabs with normal saline While turning and positioning a bedfast client the PN observes that the client is dyspneic. which action should the PN take first? apply a pulse oximeter The Client is a 50-year-old female who had a partial colectomy for diverticulitis. she has no other significant medical issues. she had a previous surgery for bunion 3 years ago. complete the diagram from the choices area to specify which condition the client is most likely experiencing. two actions the PN should take to address the condition. and two parameters the PN should monitor to assess the client's progress. action to take : Include protein supplement shakes in the client's diet, advance diet to regular as tolerated potential conditions: protein deficiency parameters to monitor signs of infections and wound healing. When calculating a client 8-hour intake, how many ML of fluid should the PN document (enter numeric value only) 0730: 120 ml of orange juice, hardboiled egg and toast 1130: 1 cup of broth, one half sandwich and 120 ml of apple juice 1400: voided 250 ml and consumed one 12 oz can of soft drink 840 ml