HESI Comprehensive Review for the
NCLEX-PN® Examination, 5th Edition:
HESI A - Fundamentals (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.
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.
,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.
ANSWER: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).
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.
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).
NCLEX-PN® Examination, 5th Edition:
HESI A - Fundamentals (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.
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.
,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.
ANSWER: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).
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.
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).
