Hesi PN Practice Exam and Questions Correct 100%

A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? A. Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations B. Change the Pleur-Evac system and re-assess output in the empty chamber C. An increase in the prescribed suction force to facilitate-drainage of serosanguineous fluids D. Advance the chest tube to ensure proper placement of the tip to enhance drainage - ANSWER B. Change the Pleur-Evac system and re-assess output in the empty chamber While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fuity odor. What assessment should the nurse perform first? A. Auscultate the client's bowel sounds B. Determine the client's capillary glucose C. Observe the color of the client's urine D. Measure the client's oxygen saturation - ANSWER B. Determine the client's capillary glucose The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client? A. Upper torso B. Head C. Feet D. Upper extremities - ANSWER A. Upper torso A 60 year-old client with cancer of the liver is in Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" B. "The nurses have not been able to arouse the client and the healthcare provider knows the outcome." C. "You need to discuss the condition with the charge nurse in a family conference." D. "The client's condition is extremely critical. Has your family made funeral arrangements?" - ANSWER A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" A client complains of kidney pain. The nurse understands that the kidneys are located where? A. On the retroperitoneal posterior abdominal wall at the costovertebral angle B. Within the curve of the duodenum, posterior to the spleen C. Lateral to the stomach in the hypochondriac region D. Superior aspect of the bladder in right and left iliac region - ANSWER A. On the retroperitoneal posterior abdominal wall at the costovertebral angle The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site? A. Umbilical area of the abdomen B. Antecubital fossae of the arm C. Chest wall below the clavicle D. Dorsal surface of the hand - ANSWER C. Chest wall below the clavicle The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number) 75mL X 15gtt/mL = 38 - ANSWER 38 The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD? A. Anemia B. Anuria C. Hypotension D. Edema - ANSWER A. Anemia The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action? A. Confirm the room and bed numbers with those on the medication record B. Ask a regular staff member to confirm the residents identity C. Hold the medication untill a family member arrives D. Re-orient the resident to name, place and situation. - ANSWER B. Ask a regular staff member to confirm the residents identity The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit? A. Edemetous lower extremities and an increased temperature B. A decreased temperature and increased blood pressure C. Dry skin and an increased heart rate D. Diaphoresis and hypertension - ANSWER C. Dry skin and an increased heart rate An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that this client is exhibiting which signs or symptom? A. Delusions of persecution B. Ideas of reference C. Hallucinations D. Confabulation - ANSWER A. Delusions of persecution The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is "gurgling" on oral secretions and coughing. Which action should the nurse take first? A. Position the client supine B. Finger sweep the oral cavity C. Perform oral suctioning D. Provide mouth care - ANSWER C. Perform oral suctioning What length of blood pressure cuff should be the nurse use when obtaining a client's blood pressure? A. A cuff that is no longer than the circumference of the extremity should be used B. The lenght of the blood pressure cuff does not make a difference C. The cuff and its bladder should be nearly encircled the the extremity's circumference D. At least two-thirs the circumference of the extremity should be coverered - ANSWER C. The cuff and its bladder should be nearly encircled the the extremity's circumference A nurse is assisting a client from the bathroom back to bed following a minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take? A. Place a cool rag on the client's head B. Suction the client's oral cavity C. Provide the client an emesis basin D. Place the client in a side-laying position - ANSWER D. Place the client in a side-laying position The nurse is caring for a 10-year-old child with hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurst take when interacting with the child and mother? A. No special precautions are needed B. Wear gloves only C. Wear gloves and a mask D. Wear a mask, gloves and gown. - ANSWER A. No special precautions are needed A 26 year-old primigravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped B. They should wait to resume sexual activities until the fatigue assorted with a new baby has passed C. They can resume sexual activity at 6 weeks postpartum D. It is best to wait until both parties feel up to having sexual intercourse - ANSWER A. They can have intercourse when the episiotomy is healed and the lochial flow has stopped The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news? A. Refer the family to a support group to find answers to their questions B. Reinforce the stages of the grieving process C. Listen to the family's reactions and reflect and their fears and concerns