HESI COMPREHENSIVE REVIEW FOR NCLEX-PN
EXAMINATION,5TH EDITION: HESI A –
FUNDAMENTALS (1) | QUESTIONS AND ANSWERS | |
GRADED A
1.An elderly female client calls the clinic and states that she feels very weak and dizzy. Further
assessment by the practical nurse (PN) indicates that the client self-administered an enema of 3
liters of tap water because she felt constipated. What is the most likely cause of the client's
symptoms?
A. Mucosal bleeding
B. Sodium retention
C. Fluid volume depletion
D. Water intoxication
D. Water Intoxication
Rationale:
Tap water is a hypotonic fluid, which can leave the intestine and enter the interstitial fluid by
osmosis, ultimately causing systemic water intoxication (D). This is manifested by weakness,
dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause
mucosal irritation, which might result in some bleeding (A), but the client would not experience
weakness and dizziness unless she were hemorrhaging. (B and C) can occur with the use of
hypertonic, rather than hypotonic, solutions.
2.A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement should the practical nurse (PN) identify that best demonstrates the client's
readiness to manage his wound care after discharge?
A. The client asks relevant questions regarding the dressing change.
B. The client states that he will be able to complete the wound care regimen.
C. The client demonstrates the wound care procedure correctly.
D. The client has all the necessary supplies for wound care.
C. The client demonstrates the wound care procedure correctly.
Rationale:
A return demonstration of a procedure (C) provides an objective assessment of the client's ability
to perform a task, whereas (A and B) are subjective measures. (D) is important but is of less
priority before discharge than the practical nurse's assessment of the client's ability to complete
the wound care.
,3.The practical nurse (PN) is applying the finger probe for continuous pulse oximetry on a client.
Which actions should help prevent skin irritation or breakdown? (Select all that apply.)
A. Rotate the probe location site every 4 to 8 hours.
B. Remove fingernail polish with acetone.
C. Cleanse with soap and water as needed.
D. Secure with gauze if client has allergy to adhesives.
E. Apply lotion before attaching the probe.
A,C, and D
Rationale:
Site rotation (A), skin cleansing (C), and avoidance of adhesives for allergies (D) should help
prevent skin irritation or breakdown. Removing fingernail polish will not help prevent skin
irritation (B), and application of lotion will not help prevent skin irritation or breakdown (E).
4.A 65-year-old client who attends an adult day care program and is wheelchair-mobile has
redness in the sacral area. Which information is most important for the practical nurse (PN) to
provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other fluids.
D. Purchase a newer model wheelchair.
B. Change positions in the chair at least every hour.
Rationale:
The most important teaching is to change positions frequently (B) because pressure is the most
significant factor related to the development of pressure ulcers. (A and C) may be beneficial as
well to promote healing and to reduce further risk. (D) is an intervention of last resort because
this will be very expensive for the client.
5. Which action is most important for the practical nurse (PN) to implement when donning sterile
gloves?
A. Maintain the thumb at a 90-degree angle.
B. Hold the hands with the fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first.
C. Keep gloved hands above the elbows.
, Rationale:
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to
maintaining asepsis. Although it may be helpful to put the glove on the dominant hand first, it is
not necessary to ensure asepsis (D).
6. The practical nurse (PN) is administering a rectal suppository to a client. What action should be
implemented to prevent discomfort during administration?
A. Place the suppository high in the rectum.
B. Freeze the suppository before insertion.
C. Allow the suppository to become soft before insertion.
D. Avoid use of a lubricant with insertion.
C. Allow the suppository to become soft before insertion.
Rationale:
Allowing the suppository to become soft before insertion (C) will decrease the possibility of
causing trauma or discomfort to the client. (A or B) would be uncomfortable and possibly
traumatize the rectal mucosa. (D) is not the standard for rectal suppository administration.
7.A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and
tachypnea. What action should the practical nurse take first?
A.
Give oxygen at 2 liters per nasal cannula.
B.
Raise the head of the bed.
C.
Observe for tracheal deviation.
D.
Reassure and stay with the client.
B.
Raise the head of the bed.
Rationale:
Raising the head of the bed (B) facilitates respiratory functioning. (A and D) are important, but
first the client should be placed in a semi-Fowler or Fowler position. Although tracheal deviation
can occur with a tension pneumothorax, the client should be placed in an upright position in the
bed (C) before further assessment is obtained.
EXAMINATION,5TH EDITION: HESI A –
FUNDAMENTALS (1) | QUESTIONS AND ANSWERS | |
GRADED A
1.An elderly female client calls the clinic and states that she feels very weak and dizzy. Further
assessment by the practical nurse (PN) indicates that the client self-administered an enema of 3
liters of tap water because she felt constipated. What is the most likely cause of the client's
symptoms?
A. Mucosal bleeding
B. Sodium retention
C. Fluid volume depletion
D. Water intoxication
D. Water Intoxication
Rationale:
Tap water is a hypotonic fluid, which can leave the intestine and enter the interstitial fluid by
osmosis, ultimately causing systemic water intoxication (D). This is manifested by weakness,
dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause
mucosal irritation, which might result in some bleeding (A), but the client would not experience
weakness and dizziness unless she were hemorrhaging. (B and C) can occur with the use of
hypertonic, rather than hypotonic, solutions.
2.A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement should the practical nurse (PN) identify that best demonstrates the client's
readiness to manage his wound care after discharge?
A. The client asks relevant questions regarding the dressing change.
B. The client states that he will be able to complete the wound care regimen.
C. The client demonstrates the wound care procedure correctly.
D. The client has all the necessary supplies for wound care.
C. The client demonstrates the wound care procedure correctly.
Rationale:
A return demonstration of a procedure (C) provides an objective assessment of the client's ability
to perform a task, whereas (A and B) are subjective measures. (D) is important but is of less
priority before discharge than the practical nurse's assessment of the client's ability to complete
the wound care.
,3.The practical nurse (PN) is applying the finger probe for continuous pulse oximetry on a client.
Which actions should help prevent skin irritation or breakdown? (Select all that apply.)
A. Rotate the probe location site every 4 to 8 hours.
B. Remove fingernail polish with acetone.
C. Cleanse with soap and water as needed.
D. Secure with gauze if client has allergy to adhesives.
E. Apply lotion before attaching the probe.
A,C, and D
Rationale:
Site rotation (A), skin cleansing (C), and avoidance of adhesives for allergies (D) should help
prevent skin irritation or breakdown. Removing fingernail polish will not help prevent skin
irritation (B), and application of lotion will not help prevent skin irritation or breakdown (E).
4.A 65-year-old client who attends an adult day care program and is wheelchair-mobile has
redness in the sacral area. Which information is most important for the practical nurse (PN) to
provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other fluids.
D. Purchase a newer model wheelchair.
B. Change positions in the chair at least every hour.
Rationale:
The most important teaching is to change positions frequently (B) because pressure is the most
significant factor related to the development of pressure ulcers. (A and C) may be beneficial as
well to promote healing and to reduce further risk. (D) is an intervention of last resort because
this will be very expensive for the client.
5. Which action is most important for the practical nurse (PN) to implement when donning sterile
gloves?
A. Maintain the thumb at a 90-degree angle.
B. Hold the hands with the fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first.
C. Keep gloved hands above the elbows.
, Rationale:
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to
maintaining asepsis. Although it may be helpful to put the glove on the dominant hand first, it is
not necessary to ensure asepsis (D).
6. The practical nurse (PN) is administering a rectal suppository to a client. What action should be
implemented to prevent discomfort during administration?
A. Place the suppository high in the rectum.
B. Freeze the suppository before insertion.
C. Allow the suppository to become soft before insertion.
D. Avoid use of a lubricant with insertion.
C. Allow the suppository to become soft before insertion.
Rationale:
Allowing the suppository to become soft before insertion (C) will decrease the possibility of
causing trauma or discomfort to the client. (A or B) would be uncomfortable and possibly
traumatize the rectal mucosa. (D) is not the standard for rectal suppository administration.
7.A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and
tachypnea. What action should the practical nurse take first?
A.
Give oxygen at 2 liters per nasal cannula.
B.
Raise the head of the bed.
C.
Observe for tracheal deviation.
D.
Reassure and stay with the client.
B.
Raise the head of the bed.
Rationale:
Raising the head of the bed (B) facilitates respiratory functioning. (A and D) are important, but
first the client should be placed in a semi-Fowler or Fowler position. Although tracheal deviation
can occur with a tension pneumothorax, the client should be placed in an upright position in the
bed (C) before further assessment is obtained.
