HESI PN EXIT EXAM TEST BANK 2020/2021 V1|Latest Version, Graded A+
a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first?
...
HESI PN EXIT EXAM TEST BANK 2020/2021 V1|Latest Version, Graded A+
a male client admitted the morning of his scheduled surgery tells the PN that he drank water last night. What intervention will the PN implement first? Correct Answer: Determine the amount of water and exact time it was taken
A client receives ondansetron prior to chemotherapy treatment.How should the PN evaluate this medication? Correct Answer: Monitor the client for nausea or vomiting following the treatment
During morning rounds a client is admitted with OCD is in the...of the same table. What intervention should the PN implement when approached? Correct Answer: Provide time for the behavior then guide the client to other activities
The PN is caring for an older adult client who is confused and spends...factor contributes to an increased risk for impaired skin integrity for this client? Correct Answer: Has increasing episodes of urinary incontinence
The pn determines that a client with cirrhosis is experiencing peripheral....take? Correct Answer: Protect the clients feet from injury
A client is admitted to the postoperative surgical unit after a left lobectomy with two chest tubes......observes the water-sealed chambers, set and prescribed suction of 20cm water...what action should the PN implement? Correct Answer: Maintain system integrity and to promote lung reexpansion
photo of chest and locating apical HR Correct Answer: just below the left nipple
At the end of a 12-hour shift the PN observes the urine in a clients drainage..what action should the PN take next? Correct Answer: note the most recent white blood count
A client with a compound fracture of the left ankle is being discharged with a below the knee cast....PN provide to the client prior to discharge? Correct Answer: never scratch under the cast
Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? Correct Answer: implement complementary pain relief methods
A male client has been diagnosed with schizophrenia is withdrawn, isolates himself in....with one or two word responses. the morning the PN observes that he...Which intervention is most important for the PN to implement? Correct Answer: Measure appropriate vital signs
The PN is assisting an unsteady client to ambulate from the bed to the bath...client loses balance and falls onto the bedside table. what action should the PN take first? Correct Answer: Stay with the client and call for assistance
The PN is assisting a female client to obtain a voided specimen for uri...meatus. Which intervention is performed next? Correct Answer: initiate the urine stream?
An 8-year old is placed in 90-90 traction for a fractured femur that resulted from...further action by the PN? Correct Answer: weights are touching the foot of the bed
The PN is reviewing diet instructions with a female client who has hyper...she has increased her intakes of protein and calories. What action should the PN take? Correct Answer: Encourage the client to continue the dietary changes she has made
A 3-year old child returns to the pediatricians office for a postoperative visit after having...procedure. The PN should expect to observe which behavior that indicates... Correct Answer: plays doctor and nurse with the dolls
The PN reviews the procedure for measuring fluid intake and output ...glomerulonephritis and is preparing for discharge from the hospital. What... Correct Answer: -why the fluid measurements need to be recoded
-which food types are included when measuring fluid take
-what container to use for the most accurate measurement
A male client receives a prescription for 3,000 mg of medication daily, which is available...taken twice daily in equal dosages.How many tablets should the PN... Correct Answer: 3
... Correct Answer: request return visit for examination after her period when hormones are lowest
A mother brings her 5-year old child to the clinic for school physical examinations. Which assessment... PN that intergenerational violence may be occurring in the home? Correct Answer: -The 6-year old son hits his younger sister during the interview
-the 10-year old daughter has circular burns on her trunk and legs
-the 3-year old has multiple bruises on the chest and both legs
A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining.At what time should the nurse expect to discontinue the intravenous therapy? Correct Answer: 1700
the PN is caring for a client who had a total laryngectomy, left radical neck dissection... client is receiving nasogastric tube feedings via an internal pump. today the rate of the feeding was increased...ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? Correct Answer: gastric residual volumes
A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Correct Answer: Ensure that all the areolar tissue of the nipple is in the infants mouth.
Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Correct Answer: deltoid
Before inserting medication into a clients vagina, what instructions should the pn... Correct Answer: urinate until bladder is empty
An 18-year old female client with pelvic inflammatory disease (PID0 asks the pn..Which information is best for the PN to provide? Correct Answer: A history of untreated gonnorhea can lead to PID
A 28-year old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement? Correct Answer: extend the leg and flex the foot?
A new mother is bottle feeding instead of breastfeeding her newborn, The PN...most effectively deal with breast engorgement and discomfort? Correct Answer: Wear a supportive bra at all times
A client with schizophrenia reports auditory hallucinations when admitted to the hospital. PN to include in the assessment of this client? Correct Answer: "what are the voices uttering?"
A young adult male tells the PN he has declared to change his hours at work so that he can...his community. Which stage of Maslow's development is this young adult attempting to achieve? Correct Answer: Self-actualiztion
A female client arrives to the clinic for an annal physical examination. when reviewing...the PN that she takes herbs for high blood pressure instead of the prescribed..important for the PN to reinforce with the client? Correct Answer: Explain risks associated with using herbs instead of the prescribed antihypertensives.
A female Native American client who is receiving chemotherapy places a native artifact...the health care provider removes the medicine wheel and tells the client "this type..hospital" what intervention should the PN implement ? Correct Answer: Act as the clients advocate when discussing the issue with the HCP
The PN is caring for a client receiving chemotherapy who has thrombocytopenia..important to include in the nursing care plan? Correct Answer: watch the client for abnormal bleeding
... Correct Answer: "it is better to obtain children acetaminophen to prevent possible side effects from the aspirin "
A client is transferred to the surgical unit from the intensive care unit after evacuation of bilateral..primary observation should the PN monitor? Correct Answer: neuro-vital signs related to bleeding and intracranial pressure
The PN is working the day shift in a long term facility and is preparing..delegate to the UAP to perform during the change of.. Correct Answer: total the clients PO intake, fill the water pitchers, empty urinals and catheter bags.
While taking the vital signs of a older male client who takes psychotropic medication...uncontrollable hand movements ad is excessively blinking his eyes, which information.... Correct Answer: screening for tardive dyskinesia
A female client tells the PN that her hemorrhoids are inflamed and hurt..the PN to implement to complete a focused assessment? Correct Answer: position client in left lateral position to inspect perianal area for fissures or sacs
the PN is implementing the plan of care for a client who admits having...indicates the highest risk for the client acting on these suicidal thoughts? Correct Answer: Begins to show signs of improvement
... Correct Answer: -Assess the condition of the IV site
-loosen tape that secures the existing tubing
-remove existing tubing and spike new tubing into bag
-clamp the IV catheter and attach the new tubing
-unclamp the tubing and IV catheter and begin the infusion
The PN observes that a male clients urinary catheter drainage tubing is...the attached to the bed frame. What action should the PN implement? Correct Answer: observe the appearance of the urine in the drainage tubing
A 150 pound adult client with Partial-thicknees burns over 40% of the body..hospital burn unit. Which observation is most important for the Pn to report... Correct Answer: urinary output of 20 mL/hr
The PN notes that an elderly client has developed nonproductive...the previous day. Vital signs are temperature 99.8 F; pulse 94; respirations 22; and BP...important for the PN to implement? Correct Answer: report the findings to the charge nurse
The PN is making shift assignment at an extended care rehabilitation...assign to the UAP. Correct Answer: -Toileting assistance for a client receiving therapy after a total hip replacement
-daily skin care for a client with a descending double barrel colostomy
-morning care for a client with a staph wound infection
A client is complaining of a tightening sensation in the fingers, nose tip and ear lobes...24...PN should be prepared to implement what measure first? Correct Answer: Obtain prescribed calcium gluconate for tetany
A clients chief complaint is being able to swallow only small bites of solid food...PN should assess for what additional information? Correct Answer: History of alcohol and tobacco use
An adult female client with type 1 diabetes mellitus is receiving 35 units of NPH insulin...PN document as evidence that the amount of insulin is inadequate... Correct Answer: Consecutive evening serum glucose readings of >260 mg/dl
The PN is assigned the care of four clients on a medical-surgical...prioritze client assessments Correct Answer: -A client who is admitted with a suspected ruptured appendix
-A client who is post-lumbar puncture is reporting a severe headache
-An older male adult with Alzheimers who wanders out of his room
-A postoperative client who needs reinforcement of discharge instruction
...the partner refuses to go. The PN suspects the injuries may be the result of... Correct Answer: Arrange to take the client to the operating room holding area for privacy
The PN is caring for a client whose urine drug screen is positive for...exhibit during cocaine withdraw Correct Answer: powerful craving for more
[Show More]
 Questions, Answers & Rationale, A+ Guide.png)
.png)
