HESI PN Preparation test Q & A with Rationale 2022/23 Update Grade A+

3. A client is receiving an anticonvulsant, diazepam, intravenously for status epilepticus. Which intervention is most important for the practical nurse (PN) to implement? a. Monitor the client’s respiratory rate and effort b. Observe the clients’ eyes for deviation to the side c. Record hourly blood pressures for the next 4 hours d. Measure hourly urinary output for the next 8 hours 4. The practical nurse (PN) administers filgrastim to a client with neutropenia. The client later complains of bone pain. Which action should the PN take? a. Reassure the client that neutropenia often causes bone pain b. Plan to administer the next dose at an alternate injection site c. Offer to administer a prescribed PRN analgesic to the client d. Prepare a variance report about the onset of pain after injection Rationale: Medullary bone pain is a side effect of filgrastim, and the PN should offer to administer an analgesic to provide pain relief. 5. The practical nurse (PN) is caring for a client who has been taking nonsteroidal anti- inflammatory drug ibuprofen for arthritic pain. Which action will the PN include in this client plan of care? a. Give the medication on an empty stomach b. Observe for signs of gastrointestinal bleeding c. Encourage the client to wear sunblock when outside d. Monitor the blood pressure frequently Rationale: A common side effect of NSAIDs is gastrointestinal (GI) distress. The PN should observe for any signs of GI bleeding, and these should be reported immediately, and the client should quit taking the medication. 6. The practical nurse (PN) reviews instructions for use of polyethylene glycol, a laxative, with a client scheduled for a colonoscopy. Which instruction should the PN include? a. Report the onset of watery diarrhea to the healthcare provider b. Dilute the liquid medication with fruit juice to mask the flavor c. Drink each glass of solution rapidly at regular specified time intervals d. Drink the solution with the evening meal before the scheduled exam Rationale: to produce the best effect, the client should be instructed to drink each glass (240 ml) of polyethylene glycol solution rapidly and at regular intervals 7. The practical nurse (PN) notifies the healthcare provider about client information using Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the PN provide first? a. A 26-year-old client b. Intravenous fluids infusing at 75 mL/hr c. Blood pressure is 80/48 mmHg d. Cholecystectomy 24 hours ago 8. The practical nurse (PN) is observing a client self-administering a dose if subcutaneous insulin. What step of the injection technique should the practical nurse (PN) reteach? a. Injects air into the insulin vial to displace the dose b. Selects the same site that was used for the previous injection c. Inserts the needle at a 90-degree angle to the skin surface d. Uses a circular motion when applying an alcohol pad to the site Rationale: The PN should reteach the client to rotate the NOON site to a site other than the same one used for the AM dose. Different sites used throughout the day may provide a varying rate of absorption related to activity. Intra-site rotation is recommended for the dose used during one specific time of the day. The other choices are acceptable techniques for subcutaneous injection of insulin. 9. The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is counting a client’s radial pulse as seen in the picture. Which action should the PN take? a. Confirm accuracy of the pulse rate obtained by the UAP b. Instruct the UAP to report any abnormal findings c. Remind the UAP to check the clients pulse volume d. Demonstrate the correct pulse site to the UAP (follow the thumb for the radial pulse, follow the pinky for the brachial) Rationale: When checking the radial pulse, the index and middle finger should be aligned with the thumb, for brachial pulse assessment should be aligned with the pinky finger. 10. The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds (4,581 grams). The infant is jittery and has a heel stick glucose level of 40 mg/dL (2.2 mmol/L or SI units) 30 minutes after birth. Based on this information, which intervention should the practical nurse (PN) implement first? a. Repeat the heel stick for glucose in one hour b. Offer nipple feedings of 10% dextrose c. Begin frequent feedings of breast milk or formula d. Assess for signs of hypocalcemia Rationale: Providing frequent feedings will reduce the infants blood glucose; we wouldn’t want to obtain another heel stick as we want to do less invasive as possible. 11. A client consumes 8 ounces (oz) of broth, 4 oz of apple juice, 4 ounces of flavored gelatin and 1 banana. During the same shift, this client receives 1 liter of IV fluid and voids 700 mL. How many mL total oral and IV intake should the PN document on the client’s medical record? (Enter numeric value only). 8 oz x 30 mL = 240 mL 4 oz x 30 mL = 120 mL 4 oz x 30 mL = 120 mL 1 L = 1000 mL Total intake = 1480 mL 12. The nurse is very busy and running late with administering medications and asks the practical nurse (PN) to administer a medication already drawn up in an unlabeled syringe. How should the PN respond? a. “You should know that I cannot administer the medication in this syringe” b. “As long as the charge nurse checks the syringe, I can give the medication” c. “Teamwork is the best approach. I will be glad to help you get caught up” d. “I am not comfortable doing that. Is there something else I can do to help you?” Rationale: Explaining your comfortability is always okay because you don’t want to jeopardize your license, so offering to help with the nurse’s other workload is being. A team player. 13. The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Irrigate an indwelling urinary catheter for a client with bladder suspension b. Obtain a post-voided residual (PVR) volume c. Empty beside drainage unit for a client with indwelling urinary catheter d. Teach the client with fluid restrictions how to measure urine output e. Transport a urine culture sample to the laboratory Rationale: The scope of practice of UAP includes personal care such as bowel and bladder care including intake and output measurements. Emptying urine from bedside drainage units and transporting specimens are tasks that can be assigned to the UAP. 14. Which intervention should the practical nurse (PN) reinforce for a client with pruritis? a. Encourage a warm sleeping environment b. Do not take any type of tub bath c. Discourage use of skin lubricants d. Keep fingernails trimmed short Rationale: Keeping fingernails short with rough edges filed helps minimize excoriation from scratching the pruritic (itch) area. 15. While administering prescription medications to an older resident in an extended care facility, the practical nurse (PN) notices that the client is having difficulty hearing. What action is most important for the PN to take? a. Speak louder so the client can hear the conversation b. Encourage the client to read the practical nurse’s lips