HESI PN Comprehensive Exam 3 Flashcards 2022/2023

  Terms in this set (100) What intervention should theA. Provide the client with finger foods. practical nurse (PN) implement to meet the physiologicDuring the manic phase of bipolar disorder, a client integrity of a client during ais often unable to sit still long enough to eat, so the manic episode of bipolarclient should be provided finger foods that can be disorder? eaten while hyperactive. A. Provide the client with finger foods. B. Restrict the client's oral fluid intake. C. Give the client low-protein, low-calorie snacks. D. Interrupt the client's performance of rituals. A client with bipolar disorder isB. Use affirmations and limit setting. being treated with cognitive therapy. Which actions shouldD. Report client's suicidal expressions to the the practical nurse (PN)therapist. implement to reenforce this treatment strategy? Select allE. Encourage substituting positive thoughts for that apply. negative thoughts. A. Recommend daily physicalClients diagnosed with bipolar disorder may activity. experience depressive thoughts and/or attempt suicide. Cognitive therapy sometimes produces B. Use affirmations and limitrelief from troubling symptoms experienced by setting. clients with bipolar disorder. Cognitive therapy allows clients to handle "thought errors" and C. Allow the client to talkbehaviors to stop negative thoughts. continuously. D. Report client's suicidal expressions to the therapist. E. Encourage substituting positive thoughts for negative thoughts. F. Reenforce relaxation techniques when experiencing negative thoughts. The practical nurse (PN) isD. Consistent hemoglobin A1c levels no greater than evaluating a client's self7%. management of type 1 diabetes mellitus (DM). Which findingsFor optimal diabetic control, evidence-based provide the best parameter inguidelines recommend an A1c target level no the client's goals for thegreater than 7% for a client with DM, which is the prevention of long-termprimary goal and indicator of effective treatment complications of DM? and diabetes management. A. Strict adherence to a diabetic diet. B. Participation in a regular exercise program. C. Scheduled administration of accurate insulin doses. D. Consistent hemoglobin A1c levels no greater than 7%. Which action should theD. Percuss the chest wall in a rhythmic fashion. practical nurse (PN) implement for a young girl with pulmonaryThick secretions that are difficult to cough up can infection who is receiving chestbe loosened by tapping, or percussing, and physiotherapy? vibrating the chest. Percussion is carried out by cupping the hands and lightly striking the chest wall A. Encourage to hold herin a rhythmic fashion over the lung segment to be breath and then cough. drained B. Administer bronchodilators after the procedure. C. Allow the child to sit in a position of choice. D. Percuss the chest wall in a rhythmic fashion. The practical nurse (PN) isC. To prevent infection in the baby's eyes. preparing to administer erythromycin (Ilotycin) 0.5%Erythromycin is prescribed in the prophylaxis of ophthalmic ointment to aophthalmia neonatorum caused by Neisseria newborn. The father asks thegonorrhea and Chlamydia trachomatis. The PN PN the purpose of thisshould explain the ointment is a prophylactic medication. What rationaletreatment to prevent infection in the baby's eyes. should the PN provide? A. To allow the baby's eyes to focus. B. To lubricate the baby's eyes. C. To prevent infection in the baby's eyes. D. Refer the father to the pediatrician. A client's cardiac telemetryC. An increase in heart rate. reveals sinus bradycardia at 40 beats/minute. An IV dose ofAtropine increases heart rate (C) by its atropine is given per holinergic effects on the sinoatrial (SA) node. Which finding should the practical nurse (PN) identify as a therapeutic response? A. A decrease in blood pressure. B. A decrease in premature contractions. C. An increase in heart rate. D. An increase in sensorium. A client is admitted with aC. An oral temperature of 101.8° F. tumor of the hypothalamus. Which finding should theThe hypothalamus controls body temperature, so practical nurse (PN) report tovariation in the temperature should be reported to the charge nurse? determine if the elevation is related to infection or cerebral pathology. A. A pulse rate of 98 beats/min. B. Respirations of 20 breaths/min. C. An oral temperature of 101.8° F. D. A blood pressure of 130/80 mm Hg. The practical nurse (PN) isD. The posterior iliac crest. reinforcing instructions to a client who is scheduled for aBone marrow samples are commonly aspirated from bone marrow aspiration. Thethe posterior iliac crest or sternum, which are PN should prepare the clientreadily accessible obtaining a specimen of bone for the procedure at whichmarrow via the biopsy needle. site? A. The femur. B. The scapula. C. The antecubital fossa. D. The posterior iliac crest. Which discharge instructionsC. Consume a low-fat diet in smaller, more frequent should the practical nurse (PN)meals. reinforce with a client who has acute cholecystitis? Clients with acute cholecystitis are placed on small, frequent low-fat meals to decrease contraction of A. Limit oral intake to threethe gallbladder, thus decreasing pain, nausea, and regular meals per day. vomiting. B. Drink fluids between meals rather than with meals. C. Consume a low-fat diet in smaller, more frequent meals. D. Limit dietary fat intake to 35% of the daily calorie intake. A male client draws back whenB. Apologize for startling the client and explain the the practical nurse (PN)need for contact. reaches over the side rails to take his blood pressure. ToNurses often have to enter a client's personal space promote effectiveto provide care, which requires respect for the communication, what shouldclient's privacy. Apologizing and explaining the the PN do? need for contact demonstrates respect and provides information so the client may understand A. Continue to perform thethe need for personal contact. procedure quickly and quietly. B. Apologize for startling the client and explain the need for contact. C. Tell the client that the blood pressure can be taken at a later time. D. Rotate the nurses who are assigned to take the client's blood pressure. A client with delirium isC. Give simple explanations about nursing care to confused and disoriented tobe given. time and place. He states he is experiencing visual illusionsD. Remove unnecessary furniture and equipment and tactile hallucinations. Whatfrom the room. actions in the plan of care should the practical nurse (PN)F. Identify oneself each time the client is implement? Select all thatapproached. apply. Explanations should be simple, concrete, and A. Interact in an energeticconcise to ensure the client's understanding and manner to dismisscooperation. Simplifying the environment reduces misperceptions. the potential for sensory-perceptual misinterpretations. The PN should introduce him- or B. Provide a wide variety ofherself with each client contact when providing environmental stimuli. nursing care. C. Give simple explanations about nursing care to be given. D. Remove unnecessary furniture and equipment from the room. E. Encourage self care to promote client independence. F. Identify oneself each time the client is approached. Following a client's bladderA. Notify the healthcare provider immediately. surgery, the practical nurse (PN) notes that the ureteralWhen ureteral stents or catheters are placed, catheter is no longer drainingpatency must be maintained to prevent urine. What action should thehydronephrosis. Any significant decrease in PN implement? drainage should be reported immediately. A. Notify the healthcare provider immediately. B. Change the client's position and continue to monitor. C. Clamp the ureteral catheter for 30 minutes. D. Irrigate the ureteral catheter with 30 ml of sterile saline. Upgrade to remove ads Only $2.99/month A male client is beingB. Avoid the use of antihistamines and alcohol. discharged after starting a new prescription of olanzapineZypexia, an atypical antipsychotic that improves (Zyprexa) for paranoidnegative symptoms, can produce sedating effects schizophrenia. Which dischargeearly in therapy, so concomitant use of alcohol or instructions should theantihistamines should be avoided to minimize practical nurse (PN) reinforcesynergistic effects. with the client? A. Sit in the sunlight for 20 minutes everyday. B. Avoid the use of antihistamines and alcohol. C. Maintain an average dietary intake of sodium. D. Defer making business decisions for a month. In which position should theD. Right-side lying. practical nurse (PN) place a client after the client has a liverThe largest lobe of the liver, which is the most biopsy? frequently biopsied site, lies in the right hypochrondriac region of the abdomen. After a liver A. Prone. biopsy, the client should be turned onto the right B. Supine. side for the first 2 hours to provide local pressure to C. Left side-lying. the puncture site to minimize bleeding. D. Right-side lying. The practical nurse isC. Insulin is needed to carry glucose into cells. discussing glucose balance with a client who is newlyThe transport of glucose occurs because insulin diagnosed with type 2 diabetescarries glucose across the cell membrane. mellitus. Which physiological process supports the movement of glucose into the cells? A. Glucose moves to low concentrations in the cell. B. Blood pressure pushes glucose into cells. C. Insulin is needed to carry glucose into cells. D. Cells absorb glucose when needed. A mother who is a single parentC. The client's support person during this of three children comes intopregnancy. the well-child clinic and tells the nurse that she needs toAn unexpected pregnancy can be a situational crisis start prenatal visits becausefor a single-parent family. Personal or family support she unexpectantly is ms and coping mechanisms should be To determine how well theidentified with this mother. client is coping with the pregnancy, which information should the practical nurse obtain? A. The type of work the client is currently doing for employment. B. The client's plans for marriage in the near future. C. The client's support person during this pregnancy. D. The client's use of any type of contraception. Which action should theC. Demonstrate to the UAP how to give a gentle practical nurse (PN) implementbath to a client. to improve delivery of care by an unlicensed assistiveThe PN should demonstrate to the UAP how to personnel (UAP) who isprovide a gentle bath, which also allows the PN to providing less than optimalrole model how to convey a sense of caring and hygienic care to older adultrespect for the client during the procedure. clients? A. Give the UAP verbal instructions on how to correctly give baths. B. Ask another staff member to provide special skin care in the afternoon. C. Demonstrate to the UAP how to give a gentle bath to a client. D. Provide the UAP with reading and resources on bathing older clients. The practical nurse (PN)D. Direct client to use the syringe to withdraw a explains details of drawing up adose of insulin from the vial. dosage of insulin and uses an insulin syringe and vial to showHands-on practice reenforces learning and a client how to manipulate theevaluates the client's understanding about handling equipment while withdrawingequipment after watching a detailed step-by-step the solution. To evaluate thedemonstration. client's understanding, what action should the PN implement next? A. Review the steps of the procedure with the client the next day. B. Give the client written materials to study and learn the procedure. C. Ask the client to explain the procedure after the demonstration. D. Direct client to use the syringe to withdraw a dose of insulin from the vial. A male client who had anA. Provide a safe environment. emergency bowel resection for a ruptured diverticulum 36The client is experiencing symptoms consistent with hours ago is displayingearly alcohol withdrawal syndrome, so should be a increased restlessness, and hispriority nursing action. During alcohol withdrawal pulse rate is 110 beats/ client can become agitated and experience He is exhibiting gross handsensory-perceptual distortions, which increases his tremors and is plucking at therisk for injury associated with pulling out intravenous sheets and gown. During the(IV) lines and tubes and with falling. next 48 hours, it is most important for the practical nurse (PN) to implement what nursing action? A. Provide a safe environment. B. Promote honest client selfappraisal. C. Educate the client about substance abuse. D. Make the client aware of treatment options. A female visitor walks up to theA. Explain that client information cannot be shared. practical nurse (PN) in the hall and asks if the male client whoMaintaining client confidentiality in clinical practice she is visiting is going tois best supported by stating that client information recover from his illness. Whichcannot be shared with others without the client's response should the PNspecified permission. provide? A. Explain that client information cannot be shared. B. Check the chart for the client's health history and information. C. Direct the visitor to talk with the charge nurse. D. Tell the visitor to inquire with the client about his status. A client with T6 spinal cordB. Palpate the client's bladder for distention. injury who is implementing intermittent catheterization forAutonomic dysreflexia, a potentially life-threatening bladder training suddenlycomplication, is manifested by elevated blood complains of a throbbingpressure in a client with a thoracic spinal cord injury. headache. The practical nurseThe most frequent cause is bladder distention, so (PN) determines the client'spalpation of the bladder for distention should be blood pressure is mented to plan interventions to relieve the What additional assessmenttriggering stimuli. should the PN implement? A. Evaluate urine volumes obtained during bladder training. B. Palpate the client's bladder for distention. C. Calculate the PO fluid intake for the day. D. Determine if a PRN antihypertensive is prescribed. The practical nurse (PN) isB. Check the client's blood pressure. caring for a female client with a T2 spinal cord injury who isIn spinal cord injuries above T6, autonomic scheduled to begin intensivedysreflexia, manifested by a sudden onset of an rehabilitation. When the PN isacute headache, results in an elevated blood assisting the client to transferpressure in response to a noxious physical stimuli. to a wheelchair, the client tellsChecking the blood pressure is the first assessment. the PN that she does not feel like getting up. The client complains of a sudden onset of a severe throbbing headache. Which action should the PN implement first? A. Report the findings to the charge nurse. B. Check the client's blood pressure. C. Check the client for an impaction. D. Encourage the client to sit upright in the wheelchair. The practical nurse (PN)B. Maintain client's NPO status. administers a prescribed opiate for a client with acuteA client with acute pancreatitis should be NPO to pancreatitis who is havingminimize pancreatic auto-digestion from pancreatic severe abdominal pain. Whichenzymes. additional intervention in the plan of care should the PN implement? A. Monitor daily serum amylase levels. B. Maintain client's NPO status. C. Give prescribed morphine PRN. D. Place client in a position of comfort. The practical nurse (PN) isC. Auscultate breath sounds before and after assessing a client who wasrespiratory exercises. transferred to the postoperative care unit 1 hourIneffective airway clearance is best revealed by an ago. What action should theinability to clear tenacious secretions. Auscultating PN implement to evaluate thebreath sounds before and after respiratory exercises client for ineffective airwayindicates if deep breathing affects abnormal breath clearance? sounds, shallow respirations, and nonproductive cough. A. Observe the client's independent use of incentive spirometer. B. Take vital signs, including body temperature, every 4 hours. C. Auscultate breath sounds before and after respiratory exercises. D. Measure oxygen saturation (SpO2) after respiratory interventions. A male client who is newlyD. Helicobacter pylori infection is a common cause diagnosed with an ulcer isof gastric ulcers. prescribed an antibiotic. He asks the practical nurse (PN)Helicobacter pylori infection promotes gastric why this treatment is necessaryulcers by enzymatic degradation of the protective for an ulcer. What informationmucous layer, so antibiotic treatment is necessary to should the PN provide?eradicate the organism and its cytotoxic action on gastric mucosal cells A. Additional treatment is indicated if he continues a spicy diet. B. Decreased gastrin production is promoted with antibiotic therapy. C. Antibiotics increase bicarbonate retention to buffer hyperacidity. D. Helicobacter pylori infection is a common cause of gastric ulcers. A male client who is newlyD. Helicobacter pylori infection is a common cause diagnosed with an ulcer isof gastric ulcers. prescribed an antibiotic. He asks the practical nurse (PN)Helicobacter pylori infection promotes gastric why this treatment is necessaryulcers by enzymatic degradation of the protective for an ulcer. What informationmucous layer, so antibiotic treatment is necessary to should the PN provide?eradicate the organism and its cytotoxic action on gastric mucosal cells. A. Additional treatment is indicated if he continues a spicy diet. B. Decreased gastrin production is promoted with antibiotic therapy. C. Antibiotics increase bicarbonate retention to buffer hyperacidity. D. Helicobacter pylori infection is a common cause of gastric ulcers. The practical nurse (PN)C. Suction the trachea and then the mouth before deflates a male client'sdeflating the cuff. tracheostomy tube cuff to evaluate his ability to swallow.The mouth and trachea should be suctioned before What action should the PNand after deflation of the tracheostomy tube's cuff implement? to minimize aspiration. A. Deflate the cuff during the client's inhalation. B. Clean the inner cannula of the tracheostomy tube. C, Suction the trachea and then the mouth before deflating the cuff. D. Measure the amount of air removed from the cuff during deflation The practical nurse (PN) gentlyA. Conveys the practical nurse's caring and support touches the shoulder of a clientwhen words are difficult. who is weeping and who does not want to be in the hospital.Nonprocedural or therapeutic touch is an effective What is the purpose of the PN'stechnique in the nurse-client relationship that use of therapeutic touch? conveys support and communicates caring to the client. A. Conveys the practical nurse's caring and support when words are difficult. B. Acts as a positive intervention in all nurse-client interactions. C. Should be avoided because of possible cultural misinterpretation. D. Best for young children and older clients with difficulty expressing self. The practical nurse (PN) isB. Allow the child to manipulate some of the reviewing preoperativeequipment to be used. instructions with a preschooler. Which technique should the PNToddlers and preschoolers should be allowed to use to most effectivelytouch and examine objects that they will come in promote the child'scontact with during the preoperative period. understanding? A. Focus on examples of how other children have done. B. Allow the child to manipulate some of the equipment to be used. C. Use cartoon analogies to explain health-related ideas. Incorrect D. Explain the sequence of events quickly to avoid distracting the child. A female client is beingD. Drink a liter of water 1 hour before the procedure. prepared for pelvic ultrasonography. WhatUltrasound uses reflected sound waves to produce information should thepictures of intra-abdominal organs, pelvis, bladder, practical nurse (PN) give thisand prostate, as specified by the prescription. For client in preparation for thepelvic ultrasonography, the client should drink a liter diagnostic test? of water before the procedure, which ensures the the echo-reflection patterns of the sonogram can A. Eat or drink nothing afterdistinguish the bladder from the reproductive midnight. organs that lie nearby. B. Empty bladder fully before arriving. C. Take enemas at home until the stool is clear of color. D. Drink a liter of water 1 hour before the procedure. Which information to improveB. Use herbs to spice up the flavor of foods instead nutritional status should theof extra salt. practical nurse (PN) offer an older female client who livesD. Cook favorite foods in bulk and freeze in alone? Select all that apply. individual serving containers. A. Decrease intake of fluids toThe use of herbs instead of extra salt minimizes the improve of fluid retention and elevated blood pressure that is common in the elderly. Cooking and freezing B. Use herbs to spice up thefavorite foods for easy preparation later is helpful in flavor of foods instead of extraimproving the overall nutrition of an older client. salt. C. Keep the environment stress-free to concentrate on eating. D. Cook favorite foods in bulk and freeze in individual serving containers. E. Use disposable dishes to reduce the need for after meal clean-up. A client admitted with majorB. Explain the purpose and implementation of depression is placed on suicidesuicide precautions. precautions. While orienting the client to the unit, whatA client on suicide precautions should be informed activity should the practicalabout the purpose and parameters of suicidal nurse (PN) implement?precautions, which include use of selected personal items under direct supervision, removal of sharp A. Assign the same unlicensedobjects, observation at frequent intervals, and assistive personnel for one onrestriction to the unit. one observations. B. Explain the purpose and implementation of suicide precautions. C. Discuss that visitors will be limited during the client's close observation period. D. Obtain the client's permission to search his personal items. The practical nurse (PN)D. Use paper towels to absorb blood for disposal in observes an unlicensedbiohazard container and treat floor with disinfectant. assistive personnel (UAP) accidentally drop a vial ofBlood is a biohazard that requires disposal and blood while placing it in astandard precautions in cleaning environmental biohazard bag for transport tocontamination of potentially blood borne the laboratory. How should thetransmission. The UAP should be instructed to wear PN direct the UAP to clean upgloves while absorbing the blood and disposing the the blood spill on the floor? pads in a biohazard bag and while cleaning the area on the floor with a disinfectant. A. Wipe the spill with disposable cloths and discard the cloths in the trash receptacle lined with plastic. B. Call housekeeping team to clean up the blood spill and decontaminate the area. C. Absorb blood with a mop head and dispose in a biohazard bag for incineration. D. Use paper towels to absorb blood for disposal in biohazard container and treat floor with disinfectant. The healthcare providerB. Remove the restraints daily to reevaluate the prescribes wrist restraints forclient's needs. an older male resident in aD. Discontinue the restraints when the client is no long term care facility who islonger at risk for self injury. confused and has pulled out his urinary catheter twice. TheRestraints should be periodically removed to practical nurse (PN) assessesdetermine if they should be continued or the client's radial pulses anddiscontinued. skin condition under the restraint every 2 hours. Which additional measures should the PN implement? Select all that apply. A. Verify that restraints are prescribed on an as-needed basis. B. Remove the restraints daily to reevaluate the client's needs. C. Ask the client for his consent to be restrained for his safety. D. Discontinue the restraints when the client is no longer at risk for self injury. E. When the time frame of the prescription has lapsed, discontinue the restraints. The practical nurse (PN)D. Discontinue the IV infusion. palpates the insertion site of an IV infusion that is pale andInfiltration is the most common complication of swollen, and determines theintravenous (IV) therapy and is evident by pale, area is cool to touch. Whichswollen, and cool tissue at the site. The first action is action should the PNto discontinue the infusion to minimize the volume implement first? of fluid extravasation. A. Report to the nurse. B. Apply warm compresses to the site. C. Monitor client's temperature q4 hours. D. Discontinue the IV infusion. The practical nurse (PN) isA. Up and back. administering an otic medication to an adult client. InThe pinna of the adult should be pulled up and which direction should the PNback, to ensure the medication flows through the pull the pinna duringexternal ear canal and to the tympanic membrane. instillation? A. Up and back. B. Down and back. C. Up and forward. D. Down and forward. What method should theC. Ask information-seeking or closed-ended practical nurse (PN) implementquestions. to elicit information from a client during an admissionClosed questions have a definite place when interview? specific essential data, such as information seeking, is needed during the initial phases of data A. Explain the purpose of thecollection. admission interview. B. Summarize with the client the information collected. C. Ask information-seeking or closed-ended questions. D. Request relatives to leave during the interview. An older client who is aD. Assist client to stand up slowly. resident in a skilled nursing facility likes to walk forBlood pressure fluctuations with position changes exercise. The client is taking aare common in the elderly and increase the risk of vasodilator for when taking medications that can cause Which action should theorthostatic hypotension. To minimize falls related to practical nurse (PN) implementdizziness with mobilization, the PN should assist the for this client? client to stand up slowly (D) before beginning to ambulate. A. Monitor blood pressure daily. B. Provide a walker for long walks. C. Document intake and output. D. Assist client to stand up slowly. Which finding requiresB. The weights are touching the floor at the end of immediate action by thethe bed. practical nurse (PN)? To ensure the weight of the Buck's traction is A. The client's affected heel iscreating a pull to reduce a fracture and relieve supported off of the bed. muscle spasms, the PN should intervene when the weights are on the floor and not hanging freely. B. The weights are touching the floor at the end of the bed. C. The affected leg and foot are resting away from the footboard. D. The client's affected leg is aligned parallel to the edge of the bed. To help prevent complicationsB. Perform neurologic assessments. for a client who is abusing amphetamines, it is importantAmphetamines are CNS stimulants that increasing for the practical nurse tocardiovascular centers. Close monitoring of a client implement what action? who is abusing amphetamines should focus on changes in cardiac or neurologic status since A. Measure intake and output. myocardial infarction and cerebral hemorrhage B. Perform neurologichave occurred from amphetamine abuse. assessments. C. Check oxygen levels frequently. D. Keep the lights on continuously. A male client who wasD. Explain the nurse-client relationship is a hospitalized for depression 1professional relationship, not a social one. month ago is being discharged. The client asks a femaleClients often view their nurses in a positive fashion practical nurse (PN) for a dateand are often reluctant to terminate the nurse-client when he gets home. Howrelationship and seek to continue social contact should the PN respond? after discharge. Helping the client clarify the professional role of the PN provides the most A. Decline and state thattherapeutic response. another person is significant to the PN. B. Explain hospital policy that does not allow nurses to date clients. C. Accept the invitation but clarify that their meeting should be platonic relationship. D. Explain the nurse-client relationship is a professional relationship, not a social one. In addition to lowering dietaryC. Include calcium and magnesium food sources sodium intake, which dietarydaily. changes should the practical nurse (PN) encourage theDiet and exercise can reduce high risk behaviors client to make when learning toand promote healthy living life styles. Adequate manage high blood pressure? levels of calcium and magnesium play a role in the maintenance of blood pressure. A. Vary the types of dairy products, such and milk and cheese. B. Select vegetable proteins, such as canned beans. C. Include calcium and magnesium food sources daily. D. Increase protein source of shellfish to most days of the week. A client is admitted withC. Check for verbal and motor response. possible head trauma after a motor vehicle collision. WhichA client experiencing a traumatic closed head injury action should the practicalshould be monitored for signs of increased nurse (PN) implement?intracranial pressure (ICP). A neurologic examination, such as the Glasgow Coma Scale, is A. Auscultate heart sounds. performed the detect early signs of ICP, as B. Monitor client's weight. manifested by changes in verbal and motor C. Check for verbal and motorresponse. response. D. Auscultate lung and abdominal sounds. A client who is takingD. Dizziness. gentamicin (Garamycin) tells the practical nurse (PN) that heGentamicin, an aminoglycoside antibiotic, is known has been hearing ringing in histo have ototoxic side effects, which are manifested ears since he began hisby tinnitus and vertigo. Complaints of ringing in the prescription. What additionalears accompanied by dizziness are early signs of assessment finding should thehearing loss and should be reported to the PN report to the healthcarehealthcare provider. provider? A. Thirst. B. Diarrhea. C. Sedation. D. Dizziness. The practical nurse (PN) isA. Meticulous skin care. caring for a client in the oliguric phase of acute renalPoor nutritional status and edema accompanying failure (ARF). What nursingrenal failure can cause skin breakdown. Meticulous action should the PNskin care, frequent turning, and special mattresses implement? are priority concepts in basic care and comfort. A. Meticulous skin care. B. Liberal fluid intake. C. Protective isolation precautions. D. High dietary protein intake. An older Hispanic woman isC. Use a translation guide with commonly used admitted to the skilled nursingpictures and phrases. facility for rehabilitation following a hip replacement.A simple translation guide using pictures and She is alert, oriented, andphrases can be used with a cooperative client in this cooperative but speaks onlynon nonacute setting. Spanish. Her adult children interpret for her when they are present. What management plan to communicate with this client should the practical nurse (PN) implement? A. Have the children arrange to have one of them present at all times. B. Communicate with the client only when the children are present and can translate. C. Use a translation guide with commonly used pictures and phrases. D. Obtain an interpreter to help the client learn English during rehabilitation. The practical nurse (PN) isD. Hormone that stimulates release of gastric juices. caring for a client with pernicious anemia. What rolePernicious anemia results from inability to absorb does gastrin play in thisvitamin B12 which requires gastric hydrochloric acid disease? for the absorption of B12 from the intestines into the blood stream. Gastrin, a hormone secreted by the A. Enzyme that assists proteingastric mucosa near the pyloric area and digestion. duodenum, stimulates the release of hydrochloric B. Hormone that stimulates theacid in the stomach. appetite. C. Enzyme that converts glucose to glycogen. D. Hormone that stimulates release of gastric juices.   A client's blood pressure isD. Check pulses distal to the insertion site hourly. being monitored with an arterial catheter placed in theArterial lines carry the risk of hemorrhage, brachial artery. To preventinfections, thrombus formation, and neurovascular neurovascular complicationsimpairment. Pulse and circulation distal to the while the catheter is in place,arterial insertion site should be assessed hourly to what action should themonitor for neurovascular impairment that can practical nurse (PN)cause irreversible tissue damage. implement? A. Perform an Allen test to validate circulation to the hand. B. Assess continuous-flush irrigation system q1 to 4 hours. C. Ensure that all tubing connections are secure. D. Check pulses distal to the insertion site hourly. A male client returns to theB. Side-lying. surgical nursing unit from the postanesthesia care unit and isThe client should be turned to a side-lying position still drowsy. The practical nurseor positioned with his head turned to the side to (PN) uses verbal stimulation toprevent aspiration. keep the client responsive. In what position should the PN place the client until he is more reactive? A. Supine. B. Side-lying. C. Head of bed at 30 degrees with head and neck midline. D. Head of bed at 45 degrees with head and neck midline.   Which information should theA. The expected benefits and outcomes of the practical nurse (PN) reenforceprocedure. for a client who has signed anD. The nature of the therapy or procedure. informed consent for aE. Potential risks of the procedure. surgery? Select all that apply. Informed consent is mandated by federal statute A. The expected benefits andand state law and requires the healthcare provider outcomes of the procedure. to disclose the nature of the therapy or procedure, the expected benefits and outcomes of the B. Exclusion of risks of notprocedure, the potential risks of the procedure, having the procedure. alternative therapies to the intended procedure including their risks and benefits, and risks of not C. Explanation abouthaving the procedure. ineffectiveness of alternative therapies. D. The nature of the therapy or procedure. E. Potential risks of the procedure. To obtain a client's apical heartA. Fifth intercostal space, left midclavicular line. rate, which anatomical location should the practical nurse (PN)The PMI of the heart is located at the fifth use when auscultating at theintercostal space, along the left midclavicular line. point of maximal impulse (PMI)? A. Fifth intercostal space, left midclavicular line. B. Second intercostal space, right midclavicular line. C. Fifth intercostal space, left anterior axillary line. D. Fourth intercostal space, left lateral sternal border.   A male client with a history of aWhen learning to use his nondominant hand, the recent stroke has right-sidedclient should be encouraged to do as much of his or paralysis, which is his dominanther hygiene as possible to progress to side, and he is unable to endence. Which action in providing hygiene should the practical nurse (PN) implement to encourage the client's rehabilitation? A. Give the client a full bed bath and back massage and provide mouth care. B. Tell the client to wash whatever is possible by himself to provide privacy. C. Ask a family member to give a full bath to evaluate ability to care for the client at home. D. Offer assistance while encouraging client to use left hand to wash face and brush teeth. A client with type 1 diabetesB. Good control of blood glucose. mellitus who uses an insulin pump comes to the clinic forBased on standardized guidelines, the client is follow-up evaluation. The clientmaintaining blood glucose levels within the defined consistently has a fasting bloodranges for tight control (fasting blood glucose 60 to glucose between 70 and 80120 mg/dl, postprandial blood glucose less than mg/dl, a postprandial blood200 mg/dl, hemoglobin A1c no greater than 7%) glucose level below 200 mg/dl, and a hemoglobin A1c level of 5.5%. What evaluation should the practical nurse (PN) convey to the client? A. Signs of insulin resistance. B. Good control of blood glucose. C. Risk for developing hypoglycemia. D. Increased risk for hyperglycemia. The practical nurse (PN) isC. Check the tubing for air leaks. caring for a client with a chest tube and finds there is anBubbling is expected in the suction control chamber absence of bubbling in theof chest tubes when suction is applied. Absence of suction control chamber of thebubbling may indicate a leak in the tubing, so the chest tube. What action shouldPN should first check all tubing connections for a the PN implement first? potential source of air leaks. A. Turn up the wall suction. B. Report the finding to the charge nurse. C. Check the tubing for air leaks. D. Add water to the suction control chamber. Twelve hours after implantationD. Stand at the head of the bed and offer support of a cervical cesium implant,for 15 minutes. the practical nurse (PN) finds the client crying. What actionThe cesium implant delivers radiation at the tumor should the PN provide?site and places healthcare workers at risk for radiation exposure. Emotional support should be A. Leave the client alone to cryprovided with bedside presence while limiting in private. radiation exposure by standing at the head of the B. Don a lead shield and sit atbed, several feet away from the implants, and by her bedside. limiting the duration of the client visit. C. Call the client on the phone and ask her why she is crying. D. Stand at the head of the bed and offer support for 15 minutes. A new mother who deliveredA. Breast feeding techniques and bottle vaginally is being dischargedsupplementation. today with her first-born infant.B. Self care of the episiotomy. Which information is mostC. Signs or symptoms of infection. important for the practical nurse (PN) to review with theSelf care and infant care are priority discharge client before she goes hometopics that should be reviewed with the client with the new infant? Select allbefore the client goes home with the baby. that apply. A. Breast feeding techniques and bottle supplementation. B. Self care of the episiotomy. C. Signs or symptoms of infection. D. Weaning from breastfeeding to bottle feeding. E. Infant immunizations during the first year. Which information is mostA. Has the client maintained NPO status for 8 hours important for the practicalbefore the ECT? nurse (PN) to obtain when preparing a client for anClients who receive ECT on an outpatient basis are electroconvulsive treatmentasked to stay NPO for 8 hours before treatment to (ECT) on an "outpatient" basis? prevent aspiration from general anesthesia. A. Has the client maintained NPO status for 8 hours before the ECT? B. Does the client understand the ECT treatment and side effects? C. Did the client take any cardiac, antihypertensive, or H2 medications? D. Are all client prostheses removed before the ECT treatment? Which action is most importantB. Wear clean gloves when in contact with wound for the practical nurse (PN) todrainage. implement when applying a wet dressing to the skin of aImpetigo, caused by group A b-hemolytic client with impetigo? Streptococci or Staphylococci, is infectious and contagious. Drainage from the lesions requires the A. Use antimicrobial soaps andimplementation of standard precautions to prevent cool solutions to cleansespread of the infection. lesions. B. Wear clean gloves when in contact with wound drainage. C. Apply topical antibiotic ointment to wound at dressing changes. D. Pour saline on 4-inch square gauze for direct application The practical nurse (PN) isA. Obesity. interviewing a client who hasB. Diabetes. intermittent chest pain whileC. Hypertension. working in the garden. WhichD. Hyperlipidemia. history should the PN obtainE. Family history. that predisposes this client to cardiovascular disease? SelectRisk factors that are related to inheritance that may all that apply. lead to cardiovascular disease include obesity, diabetes, hypertension, high cholesterol, and family A. Obesity. history. B. Diabetes. C. Hypertension. D. Hyperlipidemia. E. Family history. F. Type B personality. The practical nurse (PN) isA. Slowing heart rate below 60 beats/minute. performing a digital extraction of an impaction for an olderThe stimulation of the rectum by digital examination client. Which finding indicatesmay stimulate the vagus nerve, which then slows the to the PN that the procedureheart rate, so the client should be monitored for should be stopped? reflex bradycardia. A. Slowing heart rate below 60 beats/minute. B. Reflex incontinence of urine and stool. C. Increased blood pressure by 20 mmHg D. Increased respiratory rate by 6 breaths.   The practical nurse (PN) isD. Use a combination of the client's explanations reinforcing teaching providedand demonstration of self injection. to a male client about self administration of subcutaneousTo best evaluate learning, the PN should observe insulin. What action should thethe client demonstrating the injection procedure PN use to best evaluate thewhile explaining each step, its rationale, and client's learning? precautions. A. Give a written test on diabetic precautions and complications. B. Provide the client with reading materials and pictorial handouts. C. Ask the client if he understands all the steps of subcutaneous administration. D. Use a combination of the client's explanations and demonstration of self injection. A client who is 3 daysB. Document the finding only. postoperatively for a coronary artery bypass graft surgeryPost CABG can contribute to hypokalemia from (CABG) has a serum potassiumhemodilution, nasogastric suction, or diuretic level of 4.5 mEq/L. What actiontherapy, so monitoring serum electrolytes is should the practical nurse (PN)important to determine the client's risk for cardiac implement based on thisdysrhythmias. The client's serum potassium is within finding? normal limits (norm 3.5 to 5.0 mEq/L) and requires documentation only. A. Notify the healthcare provider. B. Document the finding only. C. Administer potassium replacement. D. Decrease the IV solution flow rate. What action should theB. Keep client awake during the day. practical nurse (PN) implement to improve the quality of sleepStimulating the client to be active and awake during for a confused client? the day allows the client to experience some fatigue by nighttime so sleep is easier to achieve. A. Give warm black tea at bedtime. B. Keep client awake during the day. C. Give routine sedative medications at HS. D. Avoid HS care 90 minutes before bedtime A 17-year-old male comes toC. Acknowledge the difficulty of this decisionthe clinic for his pre-collegemaking while supporting his desire to continue to physical examination. Duringexplore his options. the interview, he tells the practical nurse (PN) that although he has been activelyErikson's stage of adolescent sense of identity is a engaged in sports, music, anddevelopment milestone that often continues into academics, he still does notearly young adulthood when career options in know what he would like to docollege are explored. Acknowledging the teen's after graduation. How shoulddifficulty in deciding about his future offers support the PN respond?that his search is a normal stage. A. Encourage him to speak with his parents about his confusion about his future. B. Recommend that he choose one area on which to focus so that he begins to develop a firmer sense of identity. C. Acknowledge the difficulty of this decision-making while supporting his desire to continue to explore his options. D. Suggest that he explore different part-time work options while going to college. A client who is recentlyA. Obtain serum lithium blood levels once a month. diagnosed with bipolar disorder receives a newMonthly serum lithium should be monitored to prescription for lithiumensure the prescribed dosage maintains the client's (Eskalith). Which informationblood levels within a narrow therapeutic range. should the practical nurse (PN) reenforce to ensure the client's understanding? A. Obtain serum lithium blood levels once a month. B. Eliminate foods high in salt from the daily diet. C. Discontinue lithium if fine hand tremors occur. D. Withhold lithium if fever develops during a "cold." A client who delivered aC. Rinse the perineum with warm water. normal baby 4 hours ago has been unable to void. WhatNon-invasive measures, such as pouring warm water nursing intervention should theover the client's perineum to create the urge to practical nurse (PN) implementurinate should be implement first. first? A. Increase oral fluid intake to 2500 ml. B. Use urinary catheter to drain bladder. C. Rinse the perineum with warm water. D. Palpate suprapubic area for distention. The practical nurse (PN) isD. Flex and abduct hips simultaneously examining a newborn and identifies that the gluteal skinA focused assessment for congenital hip dysplasia, folds of the buttocks arewhich is manifested with uneven gluteal skin folds, uneven and one of the thighs isapparent shortening of one femur, and limited shorter than the other. Whichabduction with flexion of hips during the Ortolani assessment should the PNmaneuver, should be performed. implement next? A. Visualize the anal and urinary meatus openings. B. Manipulate both ankles for range of motion. C. Count the number of fingers and toes. D. Flex and abduct hips simultaneously The practical nurse (PN)D. Changes in consciousness. assigns the unlicensed assistive personnel (UAP) to take theIn bacterial meningitis, meningeal irritation can vital signs for a client withcause complications such as seizures and increased bacterial meningitis. Whichintracranial pressure (ICP). The UAP should be finding should the PN directdirected to report a change in the client's the UAP to reportconsciousness, which is an early sign of elevated immediately? ICP that can compromise cerebral perfusion. A. Subnormal temperatures. B. Muscle flaccidity. C. Low blood pressure. D. Changes in consciousness. Which client outcome shouldD. The client is able to dress and feed self without the practical nurse (PN)experiencing dyspnea. identify for a client with heart failure (HF)? A client with HF that is effectively managed should be independent with activities of daily living without A. The client's weight fluctuatesdyspnea. by less than 2 kg per day. B. The client requests medication for anxiety only at night. C. The heart rate increases by 50 beats per minute with mild exercise. D. The client is able to dress and feed self without experiencing dyspnea. A client visits the clinic withB. Determine if the tea is caffeinated or has an complaints of sleep loss andherbal supplement in it. wants a prescription for sleeping pills. The practicalDetermining if the tea is caffeinated is the first nurse (PN) learns that the clientaction. is also drinking tea at the evening meals. What action should the PN implement? A. Talk to the client about history of changes in sleeping habits. B. Determine if the tea is caffeinated or has an herbal supplement in it. C. Instruct the client on the appropriate dose for the sleeping pills. D. Have a translator interpret all instructions about the sleeping pills. A 9-year-old boy who had anC. Ask the child to recall the surgical event and emergency appendectomyassess his pain level. during the night awakens and starts to cry when he does notA 9-year-old can use cognitive abilities to see his parents at the stand the nurse's explanation which should He has an IV and a dressinghelp him focus and assess his postoperative pain. covering the operative site. What action should the practical nurse (PN) implement? A. Encourage the child to calm down because big boys do not cry. B. Locate his mother and ask her to stay at the bedside with her son. C. Ask the child to recall the surgical event and assess his pain level. D. Call the healthcare provider for a prescription for a different analgesic. Which acid-base imbalance is aC. Respiratory acidosis. client with a history of severe chronic obstructive pulmonaryThe retention of carbon dioxide in a client with disease (COPD) likely toCOPD causes chronic respiratory acidosis. develop? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis. A client with a massive cerebralB. Client's designation for organ donation. bleed who is diagnosed as brain dead is receivingThe family's concerns about the client's designation mechanical ventilation. Theof organ donation should be reported to the healthcare provider has justcharge nurse immediately so organ oxygenation talked to the family aboutcan be maintained until organ procurement. removing the client from life support. Which family concern should the practical nurse (PN) relay to the charge nurse immediately? A. Family request for an autopsy. B. Client's designation for organ donation. C. Referral to the coroner's office. D. Notification of the insurance company. A male client who is receivingB. Radiation therapy provides pain relief and is a hospice care receives apalliative care measure. prescription for radiation therapy for bone metastases.Palliative radiation therapy (RT) is given to relieve The client tells the practicaloncological tumor growth, pressure, and pain nurse (PN) that he is onwithout affecting a cure, so its therapeutic use in hospice. What informationproviding comfort care as a hospice-appropriate should the PN provide themeasure should be explained. client? A. Eligibility for hospice care may expire if the cancer goes into remission. B. Radiation therapy provides pain relief and is a palliative care measure. C. Cost coverage for radiation therapy is only for a cancer treatment cure. D. Bone metastases cannot be halted and radiation will not affect a cure. A client has collapsed whileD. Begin cardiac compressions. getting out of bed, has no pulse, and is not breathing.Basic Life Support (BLS) for a client who is After calling for help and anunconscious and not breathing should begin with automated externalcardiac compressions. defibrillator (AED), which action should the practical nurse (PN) take? A. Give two quick short breaths. B. Palpate for a carotid pulse. C. Defibrillate using the AED. D. Begin cardiac compressions. The practical nurse (PN) isC. Pale, cool to the touch, and diminished pulses. completing the morning focused assessment for a clientAn extremity that is pale, cool to the touch, and has who is admitted with cellulitisdecreased pulses is indicative of decreased of the right leg. Which findingperfusion that should be reported. about the client's lower extremities is most important for the PN to report immediately to the charge nurse? A. Warm with bounding pulses. B. Edematous with slow capillary refill. C. Pale, cool to the touch, and diminished pulses. D. Postural color changes when feet are dependent. When caring for a clientB. Perform fingerstick glucose readings q6 hours. receiving total parenteral nutrition (TPN), which action isTPN solutions contain a high concentration of most important for theglucose that can cause significant fluctuation in practical nurse (PN) toblood glucose levels during therapy. The PN should implement? perform fingerstick glucose readings q6 hours to evaluate the client's tolerance to the infusion rate. A. Review results of daily serum electrolyte analysis. B. Perform fingerstick glucose readings q6 hours. C. Monitor central venous catheter (CVC) site. D. Ensure infusion pump is functioning q8 hours. Which action should theA. Stay at the bedside under the prescribed time practical nurse implementexposure. when changing bed linens of a client with radioactive implant? Radiation precautions are prescribed to protect the nurse, staff, and visitors from excessive radiation A. Stay at the bedside underexposure. Thee 3 parameters include Time (near the the prescribed time exposure. source), Distance (from the source), and Shielding (lead barrier or shield between the nurse and the B. Use a N95 respirator masksource). with a special filter. C. Wear a paper gown and boots, gloves, and mask. D. Extend time after linen change to alleviate client's anxiety.   When using nonsterileB. Wash hands immediately after removing the procedure gloves, which actiongloves. should the practical nurse (PN) implement to ensure standardWashing hands immediately after removing barrier precautions are provided to allgloves Decreases the likelihood that organisms may clients? have gained access to the skin through small holes or imperfections in the gloves and reduces the A. Use gloves for any contacttransfer of microorganisms to the environment and with the client. other clients. B. Wash hands immediately after removing the gloves. C. Wash hands with gloves on before removing them. D. Use the same gloves throughout the care of the same client. A male client with acuteB. To minimize pancreatic secretions that cause pain. pancreatitis has a nasogastric tube (NGT) to suction. He asksMaintaining NPO status and removing gastric the practical nurse (PN) if hesecretions via NGT suction minimizes gastric can have some sips of water orcontents that stimulate the release of pancreatic ice chips. Which rationaleenzymes that cause auto-digestion of the pancreas should the PN explain to theand subsequent pain. client about remaining NPO? A. To prevent nausea and vomiting. B. To minimize pancreatic secretions that cause pain. C. To remove any precipitating irritants from the stomach. D. To correct fluid and electrolyte imbalance. A client who is ready forC. Consult with the anesthesia healthcare provider transport from thefor a prescribed dose of analgesia. postanesthesia care unit (PACU) to the postoperativeA client who remains in the postanesthesia care unit unit continues to complain ofmay still have residual effects of anesthesia, so the pain at the incision site. Whathealthcare provider should be consulted for a dose action should the practicalthat is reduced or different than prescribed. nurse (PN) implement? A. Administer a dose of analgesic as written in the client's postoperative prescriptions. B. Give a half-dose of the prescribed postoperative dosage of analgesic medication. C. Consult with the anesthesia healthcare provider for a prescribed dose of analgesia. D. Tell the client that pain medication cannot be given until transfer to the postoperative unit. In the prescribed clinicalC. Turn, cough, and deep-breathe q2 hours to pathway for an elderly clientprevent secretion pooling in lungs. who is bedridden after the repair of a broken hip, transferAn elderly client who is bedridden after orthopedic to the rehabilitation unit shouldsurgery is at greatest risk for hypostatic pneumonia, be implemented at 1 weekwhich can be life-threatening. Turning, coughing, postoperatively. Whichand deep-breathing q2 hours is the preventive intervention is most importantnursing measure to minimize pooling of secretions for the practical nurse (PN) toin the posterior lobes of the lungs and has the direct the unlicensed assistivehighest priority in reducing morbidity and mortality personnel (UAP) to implementin the older population. to ensure the client can progress to this expected outcome? A. Encourage isotonic and active bed exercises for progressive mobilization plan. B. Provide meals and snacks high in protein to prevent muscle loss and weakness. C. Turn, cough, and deepbreathe q2 hours to prevent secretion pooling in lungs. D. Offer fluids and urinal q2 hours to maintain hydration and bladder function. Which task should the practicalC. Toilet a client on a bladder-training regimen. nurse (PN) assign to an unlicensed assistive personnelHygiene related to elimination is within the scope of (UAP)? a UAP. A. Check medical record for new prescriptions. B. Change dressings for a client with an infected wound. C. Toilet a client on a bladdertraining regimen. D. Evaluate blood pressure for a client who has fallen. Which action should theC. Place the client in a high Fowler's position. practical nurse (PN) implement to facilitate an effective airwayTo ensure effective airway clearance, the client clearance for a client who hasshould be placed in a high Fowler's position to a stridor and is coughing whilepromote diaphragmatic excursion that helps to experiencing an allergicstrengthen coughing. reaction? A. Turn the client to a side-lying position. B. Offer the client a glass of water to drink. C. Place the client in a high Fowler's position. D. Percuss the client's back during coughing. The practical nurse (PN) isC. Blood urea nitrogen 25 mg/dl, creatinine 2.0 caring for a client followingmg/dl. aortic aneurysm resection with graft placement. WhichIncreased blood urea nitrogen (BUN) (normal 10 to laboratory finding should the20 mg/dl) and creatinine (normal 0.6 to 1.2 mg/dl) PN report to the charge nursemay indicate poor renal perfusion and should be immediately? immediately reported to prevent further deterioration in renal function. A. Hematocrit 36%, hemoglobin 12 grams/dl. B. Sodium 145 mEq/L, potassium 4.0 mEq/L. C. Blood urea nitrogen 25 mg/dl, creatinine 2.0 mg/dl. D. Partial thromboplastin time 30 seconds, prothrombin time 12 seconds. A male client in a skilledC. Assess his desire to get out of bed or remain in nursing home has metastaticbed in a position of comfort. cancer and has requested comfort care only. During theA client with metastatic disease gets weaker day, he does not want to getbecause of cachexia related to cancer, not because out of bed because he is tooof inactivity. Comfort care recognizes that the client tired and weak to sit in a decided to direct his choices during the end of He sleeps on and off all daylife experiences. The best action each day is to and night, his position isassess the client's strength, desire, and comfort changed every 2 hours, and hemeasures of his choice. is comfortable on his pain control regimen. Which action should the practical nurse (PN) implement at the beginning of the next day shift? A. Encourage client to continue activities of daily hygiene to stay active and awake. B. Assist him to sit in a chair for an hour each day and perform passive exercises. C. Assess his desire to get out of bed or remain in bed in a position of comfort. D. Awaken client during day for short time interval to facilitate nighttime sleep. The practical nurse (PN) isC. Recent streptococcal infections. obtaining a history from a client with acute glomerulonephritisThe comprehensive history from a client with acute (AGN). Which informationglomerulonephritis should include information should the PN ask to focus onabout recent streptococcal infections, such as strep this disease etiology? throat, impetigo, scarlet fever. A. Long-term analgesic use. B. A history of hypertension. C. Recent streptococcal infections. D. Repeated urinary tract infections. A client who had a cardiacA. Pedal pulse. catheterization 2 hours ago has a pressure dressing in the leftPedal pulses should be monitored q2 hours postgroin. The practical nurse (PN)cardiac catheterization to ensure arterial perfusion is taking vital signs q2 l to the femoral arterial access is intact. Which additional assessment should the PN make? A. Pedal pulse. B. Apical pulse. C. Femoral pulse. D. Brachial pulse. Which action should theC. Elevate the newly casted leg on two pillows. practical nurse implement to reduce the risk of edema for aElevating the leg to heart level using two pillows client who had a leg casthelps reduce edema formation. applied for a fractured tibia? A. Examine the cast for dents. B. Petal the edges of the cast. C. Elevate the newly casted leg on two pillows. D. Tell the client not to insert objects under the cast. A client with a spinal cord injuryD. Elevate head of the bed to a sitting position. is flushed and sweating profusely, complaining ofThe client is manifesting symptoms of autonomic headache and nausea, and hasdysreflexia. The first action is to elevate the head of an elevated blood pressurethe bed to a sitting position immediately. with a slow pulse rate. What intervention should the practical nurse (PN) implement first? A. Notify the healthcare provider immediately. B. Check urine flow from indwelling catheter. C. Administer antihypertensive medication. D. Elevate head of the bed to a sitting position. The practical nurse (PN) isA. Offer a facial tissue to blot nasal secretions after preparing to administer nasalinstilling the drops. drops into the ethmoid nasal sinus cavity. Which actionsB. Ask the client to remain supine for 5 minutes after should the PN implement? instilling the drops. A. Offer a facial tissue to blotC. Tilt the client's head backwards over the edge of nasal secretions after instillingthe bed or over a pillow. the drops. To blot nasal drainage after instilling the drops, B. Ask the client to remainfacial tissues should be offered. To administer drops supine for 5 minutes afterinto the ethmoid sinus cavity, the PN tilts the client's instilling the drops. head backwards over the edge of the bed or places a small pillow under the shoulders. The nurse asks C. Tilt the client's headthe client to remain in a supine position for 5 backwards over the edge ofminutes after instilling the drops to prevent the bed or over a pillow. premature loss of medication through the nares. D. Hold the dropper inside the nares to instill drops at posterior nasal septum. E. Encourage client to blow nose after instillation when mucus is loosened. A client with deep partial-A. Administer prescribed morphine sulfate before thickness (second-degree)dressing changes. burns over 70% of his body experiences severe pain withNausea and vomiting may be caused by severe nausea when he is turned forpain. Pain control should be a priority nursing dressing changes. What actionintervention prior to dressing changes for a client should the practical nurse (PN)with partial-thickness burns. implement? A. Administer prescribed morphine sulfate before dressing changes. B. Give prescribed prochlorperazine (Compazine) before moving the client. C. Restrict the client's PO intake 2 hours before and after dressing changes. D. Minimize activities close to meal times to reduce the client's nausea. What should the practicalD. Use nonverbal cues such as leaning forward, nurse (PN) implement whenfocusing on the client's face, and slightly nodding. using active listening as a therapeutic technique duringUsing nonverbal cues is a succinct description of client interaction? the active listening technique. A. Focus on the client with direct eye contact to allow the client to express self freely. B. Ask probing questions to direct the conversation so specific information can be obtained. C. Anticipate what the client is trying to say and assist by finishing incomplete sentences. D. Use nonverbal cues such as leaning forward, focusing on the client's face, and slightly nodding. A male client is admitted to theC. Preoperative instructions regarding the planned hospital for placement of asurgery. gastrostomy tube (GT) for enteral feedings and plans toPreoperative preparation for the procedure is the return home where he livespriority because it is vital that the client understands alone. Which information isthe perioperative prescriptions, such as remaining most important for theNPO. practical nurse (PN) to provide to the client? A. Care of the GT at home. Incorrect B. Handwashing technique. C. Preoperative instructions regarding the planned surgery. D. Information about various types of tu