HESI COMPREHENSIVE REVIEW FOR THE NCLEX-PN®
EXAMINATION, 9TH EDITION: HESI A -
FUNDAMENTALS (1 & 2) STUDY GUIDE WITH
COMPLETE SOLUTION!!
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
answers: 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.
answers: 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.
answers: 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.
answers: 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.
answers: 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).
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.
answers: 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.
EXAMINATION, 9TH EDITION: HESI A -
FUNDAMENTALS (1 & 2) STUDY GUIDE WITH
COMPLETE SOLUTION!!
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
answers: 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.
answers: 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.
answers: 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.
answers: 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.
answers: 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).
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.
answers: 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.
