HESI PN EXIT EXAM NEW PACKAGE

1. 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 2. 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 3. The PN is assisting a female client to obtain a voided specimen for uri. .meatus. Which intervention is performed next? Initiate the urine stream? 4. 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 5. 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 6. The PN reviews the procedure for measuring fluid intake and output glomerulonephritis and is Preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded 7. The nurse is changing the dressing on a client’s wound. The nurse understands which of the following symptoms indicate a wound infection? Redness over 1 cm wide on per wound skin and tenderness 8. The nurse is developing a teaching plan for a client who is going home with a tracheostomy tube. Which of the following is the MOST important part of the teaching plan? The family of a client should know what to do in a case of emergency, i.e.: clogged tracheostomy tube and how to suction the client. 9. A 64-year-old male client comes to the provider’s office and complains of both legs hurting him when he walks a few blocks in his neighborhood. He states “When I sit down for a while, the pain eases off, but if I start walking a few blocks more, the pain comes back. The nurse recognizes this symptom may be related to peripheral vascular disease and is called what? Intermittent claudication 10. A narrowing and hardening of the arteries is called: Arteriosclerosis 11. A client has clusters of small vesicles over the thoracic region and describes severe pain and itching of the affected areas. Herpes zoster is diagnosed, and the client will be treated with which of these medications? Acyclovir (Zorivax) 12. When administrating oxygen to clients with conditions such as emphysema, it is important for the nurse to remember which one of the following facts as most important The drive to breathe may be dependent on low levels of oxygen in the blood 13. The nurse is preparing to instruct the client with pneumonia on managing the disease after discharge from the hospital. Which of the following is consistent with appropriate discharge planning for this client? Take all medications until they are finished, as ordered by MD 14. Immediately after sustaining severe burn wounds, the nurse would anticipate the client’s initial nutritional needs would usually be met by which of these methods? Total parenteral nutrition (TPN) 15. Which of the following measures should the nurse take when care for a client with TB in an acute care facility? Double-bag and dispose of client secretions as infectious waste 16. The most important nursing intervention for the nurse to remember in administrating Digoxin to a client is to? Take apical pule and withhold med is pulse is 60 17. The nurse is performing a respiratory assessment on a new client who has come to the clinic. On inspection of the anterior and posterior chest, she notices the symmetry of the chest is equal from front to back and from shoulder to shoulder like the shape of a barrel. The nurse knows the most common lung disease process causing this change in chest symmetry is? COPD 18. A nurse is reinforcing health teaching regarding skin cancer to a group of clients. Which of the following should the nurse identify as the leading cause of skin cancer? Sun exposure 19. Which of the following is potassium sparing diuretic? Aldactone 20. There are many types of wound dressings and therapies in evidence-based wound care. The wound vac has been around many years and is one of the best ways to heal a wound 60% faster than conventional dressings because? (select all that apply) -Negative pressure increases epithelial cell multiplications forming granulation tissue -Reduces edema in the wound and improves blood flow 21. A nurse is collecting data from a client who present to the provider’s office for evaluation pf multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? Irregular borders 22. Which breath sounds are usually heard over the anterior third of the chest near the sternum and also scapular posteriorly, and have inspiration and expiration of equal duration? Bronchovesicular 23. Frank is a 4 year old paraplegic client with cerebral palsy who was admitted to the hospital with complications from the H1N1 virus. The nurse who was admitting him noted that he had an area of redness on his right malleolus that was non-blanchable. The nurse correctly identified this area as what stage of a pressure ulcer? Stage 1 24. 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 25. 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 26. 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. 27. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Deltoid 28. A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the LPN/LVN to include in this client's plan of care while the client is taking the antidepressant? Mood 29. Based on the documentation in the medical record, which action should the LPN/LVN implement next? Give the rubella vaccine subcutaneously 30. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the LPN/LVN implement to prevent complications associated with Pneumonia? Encourage mobilization and ambulation 31. Which nursing activity is within the scope of practice for the practical nurse? Observe a client rotate the subcutaneous site for an insulin pump 32. After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? Provide perianal care and collect clean linens for the dressing change 33. Which ethnic group aged 45-74 has a higher chance of coronary artery disease than men and women in the same age group? African American 34. There are certain risk factors associated with cardiovascular disease. Which of these would be considered an alterable risk factor? Physical activity 35. A severe potential surgical complication from an aortic aneurysm repair is? Hemorrhage 36. Every in-patient facility should have a type of scoring tool for nurses to assess their clients for risk of pressure ulcers. One of the most common and research-based tools currently used is called what? Braden Scale 37. A nurse is conducting a health and wellness seminar for a local community center. Cardiac care is the topic and the nurse is reviewing different types of cardiac infections including endocarditis. Which of the following puts the client most at risk for endocarditis? Dental caries 38. Increasing the protein vitamin C, and iron in the diet will enhance tissue regeneration. Which one of the following food combinations would the nurse recommend to a client to assist healing of a venous stasis ulcer? Roast beef and spinach salad 39. A client is admitted to the hospital. The nurse needs to document the client’s weight in kilograms. The client weighs 156 pounds. How many kilograms does the client weigh? 70.9 kg 40. 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 41. Six hours after removing a client’s 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 42. 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 43. The PN is reviewing the state nurse practice act. What information will be included within the document? Legal requirements for PN 44. The LPN/LVN is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catheterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take? Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. 45. A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects? Moon face, Slow wound healing, muscle wasting sodium and water retention 46. The cervix is the opening into the uterine cavity. What is its function in reproduction? Secretes mucus to facilitate sperm transport 47. The LPN/LVN is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? 17-year-old who is sexually active simultaneously with numerous partners 48. The LPN/LVN is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate? Conversion of irregular heart rate to regular heart rhythm 49. An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? Increase the fluid intake in your diet 50. The LPN/LVN 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? The lips and mucus membranes of a client with dark skin are dusky in color 51. When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes during flow into the tubing. What action is taken next? Insert the catheter an additional inch 52. A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus 53. Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? Use of careful hand washing technique 54. 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 55. 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 56. 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 57. 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 58. During the assessment go a school age child the PN determines that the client is in Erickson’s developmental stage of industry vs inferiority. Which behavior did the client demonstrate? Sitting quietly reading a book 59. A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? Provide oral care 60. The PN is caring for a client in buck’s tract what is the priority goal for the client in traction? Maintain straight body alignment 61. Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? Offer emotional support to the family 62. 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 emesis accurately 63. 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 64. 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 65. 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 66. Which picture of nailbeds indicate hypoxia? Choose the one that has a bump right below the nail bed 67. The LPN/LVN is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? The infusion site is infiltrated 68. The LPN/LVN observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? Observe the appearance of the urine in the drainage tubing 69. In assisting a client to obtain a sputum specimen, the LPN/LVN observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? Re-instruct the client in coughing techniques to obtain another specimen 70. After report, the LPN/LVN receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is..... Trembling and has a glucose level of 50 mg/dL 71. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take? Give the client crackers and milk 72. The LPN/LVN is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage? Cut the bag opening to the measurement of the stoma size 73. Prior to administering morphine sulfate (Morphine), the LPN/LVN takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified? A respiratory rate of 10 breaths per minute 74. Following an open reduction of the tibian, the LPN/LVN notes fresh bleeding on the client's cast. Which intervention should the nurse implement? Outline the area with ink and check it q15 minutes to see if the area has increased 75. The LPN is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "What do these letters T1N0M0, stand for?" which response should the nurse provide first? "The letters stand for tumor size, node involvement and metastasis." 76. The LPN/LVN plans to administer the rubella vaccine to a postpartum client whose titer is 1:8 and who is breastfeeding? What information should the nurse provide this client? The vaccine is given to produce maternal antibodies before lactation occurs 77. In counting a client's radial pulse, the LPN/LVN notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? Count the apical pulse rate for sixty seconds 78. Which structures are located in the subcutaneous layer of the skin? Adipose cells and blood vessels 79. The LPN/LVN in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients? Cleanse the perineal area of a client with urinary incontinence 80. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? Longitudinally from the right forehead to the right cheek 81. 36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? Palpate the bladder for distention 82. A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? Determine respiratory status and apply a pulse oximeter 83. The LPN/LVN is administering multiple medications to a 78-year-old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make? Cumulative serum drug levels and toxicity 84. In obtaining an orthostatic vital sign measurement, what action should the nurse take first? Instruct the client to lie supine 85. A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period? Nipple feedings with glucose water 86. Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the nurse. After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a Semi-Fowler's position. However, the nurse meets resistance and the clients’ voices discomfort. What action should the nurse take next? Assist the client in taking a series of deep breaths 87. 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 88. 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 89. A client’s blood pressure is unusually elevated. Which factors would contribute to this client’s blood pressure elevation? Stress 90. To obtain an estimate of a client’s systolic blood pressure, what action should the PN take first? Palpate the client’s brachial pulse 91. A client reports feeling numbness and tingling in extremities. What action should the PN implement? Review the client’s serum electrolyte levels 92. Immediately after birth, which nursing intervention has the highest priority for the newborn infant? Preventing heat loss and neonatal cold stress 93. A 0800 a client’s 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 94. 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 95. 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 96. 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 97. 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 98. 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 99. A LPN/LVN is contributing to a care plan for an adolescent female client with Anorexia Nervosa. Which outcome statement or goal would be most appropriate for this client? She will develop a positive body image and self- identity 100. A female client with no family history of Breast Cancer (BA) asks the nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question? Breastfeeding history 101. The LPN/LVN is working on the postpartum unit and is assisting a new mother with her newborn's diaper change. The mother states that the infant fed well and completed the whole bottle of formula. What action should the nurse implement first when the infant begins to spit up during the diaper change? Turn the newborn and bulb suction the mouth and nose 102. An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond? Request that the client clarify his religious beliefs about bathing 103. A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide? State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection 104. The scope of practice for the practical nurse includes which client assessments? Transfer of a client with sepsis from a long-term care facility 105. What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? Cleanse the radiated area with water and pat the skin dry 106. Which organ lays retroperitoeally? Kidneys 107. The LPN/LVN is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department? After breakfast 108. The LPN/LVN is planning to ambulate client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first? Assist the client to a bedside sitting position 109. A Client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture? The neck extended backward using a rolled towel behind the neck 110. A client receives a new prescription for the angiot