Fundamentals - HESI : PN
A client is undergoing chemotherapy treatment and has a decreased neutrophil count. The client is
under protective (reverse, or neutropenic) precautions. While the nurse is caring for the client, the
client hands her cell phone to the nurse and says, “This is my pastor, can you explain to him about
this isolation stuff?” Which comments are most appropriate for the nurse to make?
(Select all that apply.)
a. “Her white blood cells are dangerously low right now.”
b. “She would probably enjoy visits from your preschool choir.”
c. “If her white blood cells drop any further, she will be on isolation a long time.”
d. “I think she would benefit from members of the congregation phoning her.”
e. “She can communicate with others via email or texting.”
f. “Could you send her flowers from your congregation?”
D) “I think she would benefit from members of the congregation phoning her.”
ANSWER:E) “She can communicate with others via email or texting.”
Rationale:
,A client under protective (reverse or neutropenic) precautions due to an increased risk of infection
due to a low neutrophil count. The client can communicate with others via phone, email or texting.
The client cannot have visits from children, and cannot have flowers or plants in the room, due to a
risk of infection. It is a violation of client privacy rights to discuss the client’s white blood cells
counts. The client asked the nurse to provide information about the precautions in place, not her
white blood cells.
Which client finding requires further action by the practical nurse (PN)?
a. A disoriented client’s soft wrist restraints are tied to the bed frame.
b. The drainage tube of an indwelling catheter is looped below the client’s bladder.
c. The aspirant of a client’s nasogastric tube has a pH of 4.
d. Skin over the coccyx blanches when the client is repositioned to a lateral position.
ANSWER:B) The drainage tube of an indwelling catheter is looped below the client’s bladder.
Rationale:
Urine collecting in a loop of tubing that is dependent will not drain properly and places the client at
risk for infection, so the (PN) should reposition the urinary drainage tube to eliminate looping below
the bladder.
An older adult client has been diagnosed with Clostridium difficile (C. Diff)–associated diarrhea.
Which is the best method to prevent transmission of the disease to other clients in the long-term
care facility?
,a. Adequate handwashing with soap and water
b. Conducting cultures of all the employees’ stools
c. Asking staff members to stay home if they develop diarrhea
d. Installing alcohol based hand sanitizer inside each client’s door
ANSWER:A) Adequate handwashing with soap and water
Rationale:
The organism that causes C. Diff–associated diarrhea is not killed by alcohol-based hand sanitizers.
Adequate handwashing with soap and water is the best way to prevent the spread of the disease
since it helps remove most of the microorganism on the hands of staff members. Employees should
stay home if they develop diarrhea, but this is not specific to C. Diff–associated diarrhea. Collecting
stool samples from employees would not stop the spread of the disease.
The nurse is shopping at a mall when an individual with a large machete suddenly starts stabbing
other shoppers. Security police have captured the assailant. Multiple shoppers and mall employees
immediately left the premises. Which victim should the nurse attend first until first responders
arrive?
A) An individual whose head is completely severed.
B) An individual with a pulsating gash to the forearm.
C) An individual whose ankle was twisted running from the scene.
D) An individual who has no palpable pulse and no respiratory effort.
, ANSWER:B) An individual with a pulsating gash to the forearm.
Rationale:
The nurse should attend to the individual with a pulsating gash to the forearm. It is likely the nurse
can slow the bleeding by applying direct pressure or a tourniquet to the arm. The individual whose
head is completely severed is dead. The individual who has no pulse would require a great deal of
resources while the individual whose arm is severed could be attended to by one individual. The
individual with a twisted ankle can be treated at a later time.
The practical nurse (PN) is performing nasotracheal suctioning. After the client’s trachea is suctioned
for 10 seconds, large amounts of thick yellow secretions return. What action should the PN
implement next?
a. Encourage the client to cough to help loosen secretions.
b. Advise the client to increase intake of oral fluids.
c. Rotate the suction catheter to obtain any remaining secretions.
d. Reoxygenate the client before attempting to suction again.
ANSWER:D) Reoxygenate the client before attempting to suction again.
Rationale:
Suctioning should not be continued for longer than 10 seconds because the client’s oxygenation is
compromised during this time.
A client is undergoing chemotherapy treatment and has a decreased neutrophil count. The client is
under protective (reverse, or neutropenic) precautions. While the nurse is caring for the client, the
client hands her cell phone to the nurse and says, “This is my pastor, can you explain to him about
this isolation stuff?” Which comments are most appropriate for the nurse to make?
(Select all that apply.)
a. “Her white blood cells are dangerously low right now.”
b. “She would probably enjoy visits from your preschool choir.”
c. “If her white blood cells drop any further, she will be on isolation a long time.”
d. “I think she would benefit from members of the congregation phoning her.”
e. “She can communicate with others via email or texting.”
f. “Could you send her flowers from your congregation?”
D) “I think she would benefit from members of the congregation phoning her.”
ANSWER:E) “She can communicate with others via email or texting.”
Rationale:
,A client under protective (reverse or neutropenic) precautions due to an increased risk of infection
due to a low neutrophil count. The client can communicate with others via phone, email or texting.
The client cannot have visits from children, and cannot have flowers or plants in the room, due to a
risk of infection. It is a violation of client privacy rights to discuss the client’s white blood cells
counts. The client asked the nurse to provide information about the precautions in place, not her
white blood cells.
Which client finding requires further action by the practical nurse (PN)?
a. A disoriented client’s soft wrist restraints are tied to the bed frame.
b. The drainage tube of an indwelling catheter is looped below the client’s bladder.
c. The aspirant of a client’s nasogastric tube has a pH of 4.
d. Skin over the coccyx blanches when the client is repositioned to a lateral position.
ANSWER:B) The drainage tube of an indwelling catheter is looped below the client’s bladder.
Rationale:
Urine collecting in a loop of tubing that is dependent will not drain properly and places the client at
risk for infection, so the (PN) should reposition the urinary drainage tube to eliminate looping below
the bladder.
An older adult client has been diagnosed with Clostridium difficile (C. Diff)–associated diarrhea.
Which is the best method to prevent transmission of the disease to other clients in the long-term
care facility?
,a. Adequate handwashing with soap and water
b. Conducting cultures of all the employees’ stools
c. Asking staff members to stay home if they develop diarrhea
d. Installing alcohol based hand sanitizer inside each client’s door
ANSWER:A) Adequate handwashing with soap and water
Rationale:
The organism that causes C. Diff–associated diarrhea is not killed by alcohol-based hand sanitizers.
Adequate handwashing with soap and water is the best way to prevent the spread of the disease
since it helps remove most of the microorganism on the hands of staff members. Employees should
stay home if they develop diarrhea, but this is not specific to C. Diff–associated diarrhea. Collecting
stool samples from employees would not stop the spread of the disease.
The nurse is shopping at a mall when an individual with a large machete suddenly starts stabbing
other shoppers. Security police have captured the assailant. Multiple shoppers and mall employees
immediately left the premises. Which victim should the nurse attend first until first responders
arrive?
A) An individual whose head is completely severed.
B) An individual with a pulsating gash to the forearm.
C) An individual whose ankle was twisted running from the scene.
D) An individual who has no palpable pulse and no respiratory effort.
, ANSWER:B) An individual with a pulsating gash to the forearm.
Rationale:
The nurse should attend to the individual with a pulsating gash to the forearm. It is likely the nurse
can slow the bleeding by applying direct pressure or a tourniquet to the arm. The individual whose
head is completely severed is dead. The individual who has no pulse would require a great deal of
resources while the individual whose arm is severed could be attended to by one individual. The
individual with a twisted ankle can be treated at a later time.
The practical nurse (PN) is performing nasotracheal suctioning. After the client’s trachea is suctioned
for 10 seconds, large amounts of thick yellow secretions return. What action should the PN
implement next?
a. Encourage the client to cough to help loosen secretions.
b. Advise the client to increase intake of oral fluids.
c. Rotate the suction catheter to obtain any remaining secretions.
d. Reoxygenate the client before attempting to suction again.
ANSWER:D) Reoxygenate the client before attempting to suction again.
Rationale:
Suctioning should not be continued for longer than 10 seconds because the client’s oxygenation is
compromised during this time.
