HESI PN EXIT EXAM TEST BANK 2020/2021 V1|Latest Version, Graded
A+
a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night.
What intervention will the PN implement first? Correct Answer: Determine the amount of water and
exact time it was taken
A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this
medication? Correct Answer: Monitor the client for nausea or vomiting following the treatment
During morning rounds a client is admitted with OCD is in the...of the same table. What intervention
should the PN implement when approached? Correct Answer: Provide time for the behavior then guide
the client to other activities
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? Correct Answer: Has increasing episodes of urinary
incontinence
The pn determines that a client with cirrhosis is experiencing peripheral....take? Correct Answer:
Protect the clients feet from injury
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? Correct Answer: Maintain system integrity and to promote lung reexpansion
photo of chest and locating apical HR Correct Answer: just below the left nipple
At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN
take next? Correct Answer: note the most recent white blood count
A client with a compound fracture of the left ankle is being discharged with a below the knee cast....PN
provide to the client prior to discharge? Correct Answer: never scratch under the cast
Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what
action should the PN implement first? Correct Answer: implement complementary pain relief methods
A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two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? Correct Answer: Measure appropriate vital signs
The PN is assisting an unsteady client to ambulate from the bed to the bath...client loses balance and
falls onto the bedside table. what action should the PN take first? Correct Answer: Stay with the client
and call for assistance
The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is
performed next? Correct Answer: initiate the urine stream?
,An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the
PN? Correct Answer: weights are touching the foot of the bed
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? Correct Answer: Encourage the client to
continue the dietary changes she has made
A 3-year old child returns to the pediatricians office for a postoperative visit after having...procedure.
The PN should expect to observe which behavior that indicates... Correct Answer: plays doctor and
nurse with the dolls
The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is
preparing for discharge from the hospital. What... Correct Answer: -why the fluid measurements need
to be recoded
-which food types are included when measuring fluid take
-what container to use for the most accurate measurement
A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice
daily in equal dosages.How many tablets should the PN... Correct Answer: 3
... Correct Answer: request return visit for examination after her period when hormones are lowest
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? Correct Answer: -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
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? Correct Answer: 1700
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? Correct
Answer: gastric residual volumes
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? Correct Answer: Ensure that all
the areolar tissue of the nipple is in the infants mouth.
Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum
client? Correct Answer: deltoid
Before inserting medication into a clients vagina, what instructions should the pn... Correct Answer:
urinate until bladder is empty
, An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is
best for the PN to provide? Correct Answer: A history of untreated gonnorhea can lead to PID
A 28-year old client is in active labor and complains of a cramp in her leg. What intervention should the
PN implement? Correct Answer: extend the leg and flex the foot?
A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal
with breast engorgement and discomfort? Correct Answer: Wear a supportive bra at all times
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include
in the assessment of this client? Correct Answer: "what are the voices uttering?"
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? Correct
Answer: Self-actualiztion
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? Correct Answer: Explain risks associated with using herbs instead of the prescribed
antihypertensives.
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 ? Correct Answer: Act as the clients advocate when discussing the issue with the HCP
The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in
the nursing care plan? Correct Answer: watch the client for abnormal bleeding
... Correct Answer: "it is better to obtain children acetaminophen to prevent possible side effects from
the aspirin "
A client is transferred to the surgical unit from the intensive care unit after evacuation of
bilateral..primary observation should the PN monitor? Correct Answer: neuro-vital signs related to
bleeding and intracranial pressure
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.. Correct Answer: total the clients PO intake, fill the water pitchers, empty urinals
and catheter bags.
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.... Correct Answer: screening for
tardive dyskinesia
A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to
complete a focused assessment? Correct Answer: position client in left lateral position to inspect
perianal area for fissures or sacs
A+
a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night.
What intervention will the PN implement first? Correct Answer: Determine the amount of water and
exact time it was taken
A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this
medication? Correct Answer: Monitor the client for nausea or vomiting following the treatment
During morning rounds a client is admitted with OCD is in the...of the same table. What intervention
should the PN implement when approached? Correct Answer: Provide time for the behavior then guide
the client to other activities
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? Correct Answer: Has increasing episodes of urinary
incontinence
The pn determines that a client with cirrhosis is experiencing peripheral....take? Correct Answer:
Protect the clients feet from injury
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? Correct Answer: Maintain system integrity and to promote lung reexpansion
photo of chest and locating apical HR Correct Answer: just below the left nipple
At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN
take next? Correct Answer: note the most recent white blood count
A client with a compound fracture of the left ankle is being discharged with a below the knee cast....PN
provide to the client prior to discharge? Correct Answer: never scratch under the cast
Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what
action should the PN implement first? Correct Answer: implement complementary pain relief methods
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? Correct Answer: Measure appropriate vital signs
The PN is assisting an unsteady client to ambulate from the bed to the bath...client loses balance and
falls onto the bedside table. what action should the PN take first? Correct Answer: Stay with the client
and call for assistance
The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is
performed next? Correct Answer: initiate the urine stream?
,An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the
PN? Correct Answer: weights are touching the foot of the bed
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? Correct Answer: Encourage the client to
continue the dietary changes she has made
A 3-year old child returns to the pediatricians office for a postoperative visit after having...procedure.
The PN should expect to observe which behavior that indicates... Correct Answer: plays doctor and
nurse with the dolls
The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is
preparing for discharge from the hospital. What... Correct Answer: -why the fluid measurements need
to be recoded
-which food types are included when measuring fluid take
-what container to use for the most accurate measurement
A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice
daily in equal dosages.How many tablets should the PN... Correct Answer: 3
... Correct Answer: request return visit for examination after her period when hormones are lowest
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? Correct Answer: -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
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? Correct Answer: 1700
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? Correct
Answer: gastric residual volumes
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? Correct Answer: Ensure that all
the areolar tissue of the nipple is in the infants mouth.
Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum
client? Correct Answer: deltoid
Before inserting medication into a clients vagina, what instructions should the pn... Correct Answer:
urinate until bladder is empty
, An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is
best for the PN to provide? Correct Answer: A history of untreated gonnorhea can lead to PID
A 28-year old client is in active labor and complains of a cramp in her leg. What intervention should the
PN implement? Correct Answer: extend the leg and flex the foot?
A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal
with breast engorgement and discomfort? Correct Answer: Wear a supportive bra at all times
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include
in the assessment of this client? Correct Answer: "what are the voices uttering?"
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? Correct
Answer: Self-actualiztion
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? Correct Answer: Explain risks associated with using herbs instead of the prescribed
antihypertensives.
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 ? Correct Answer: Act as the clients advocate when discussing the issue with the HCP
The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in
the nursing care plan? Correct Answer: watch the client for abnormal bleeding
... Correct Answer: "it is better to obtain children acetaminophen to prevent possible side effects from
the aspirin "
A client is transferred to the surgical unit from the intensive care unit after evacuation of
bilateral..primary observation should the PN monitor? Correct Answer: neuro-vital signs related to
bleeding and intracranial pressure
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.. Correct Answer: total the clients PO intake, fill the water pitchers, empty urinals
and catheter bags.
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.... Correct Answer: screening for
tardive dyskinesia
A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to
complete a focused assessment? Correct Answer: position client in left lateral position to inspect
perianal area for fissures or sacs
