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D&D HESI PN Exam Review
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D&D HESI PN Exam Review
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D&D HESI PN Exam ReviewA client returns to the postoperative unit following an open reduction and internal fixation of a hip fx. the PN
applies the prescribed sequential compression device (SCD) to both lower extremities. WHAT ACTION IS
IMPORTANT WHEN TURNING THE CLIENT TO A LATERAL POSITION? - ANSWER-Observe the SCDs continue to
inflate and deflate when the client is turned.
While the PN assists a postoperative client with an incentive spirometer, the client experiences wound
evisceration. WHAT ACTION SHOULD THE PN TAKE? - ANSWER-Call for immediate assistance.
The PN finds a postoperative client lying in bed with a unsecured surgical dressing. After reinforcing the
dressing, WHAT FOLLOW UP ASSESSMENT IS MOST IMPORTANT FOR THE PN TO IMPLEMENT? - ANSWER-Vital
signs measurement.
The scope of practice for the PN includes which CLIENT ASSESSMENT? - ANSWER-An agitated client with b/l
wrist restraints.
Which intervention is within the scope of practice for a PN? - ANSWER-Demonstrating deep breathing and
coughing to a postoperative client.
Which nursing activity is within the scope of practice for a PN? - ANSWER-Observe client rotate the SQ site for
an insulin pump.
,The nurse is assessing care for residents on 12-bed unit in an extended care facility. The staff consists of 1
unlicensed UAP and 1 certified medication aide. WHICH TASK SHOULD THE NURSE PERFORM? - ANSWER-
Change a hydrocolloid dressing for a client with a stage II pressure ulcer.
A PN who works on a 16-bed of an extended care facility with an additional P and a UAP is told that the other
PN will not be in because of illness. The facility manager agrees to obtain another UAP for the day. WHICH
ACTION SHOULD THE PN TAKE? - ANSWER-Prioritize assessment of safety issues in addition to administration of
daily medication.
In working with UAP to provide care for an immobile client, WHICH TASK SHOULD THE NURSE PERFORM,
RATHER THAN THE UAP? - ANSWER-Cover a skin tear with a transparent dressing.
A nurse sees a college taking drugs from the hospital unit. WHAT ACTION SHOULD THE NURSE TAKE? -
ANSWER-Report the incident to the person in charge of the unit or nursing supervisor.
The PN finds a client who is assigned to another nurse bleeding from an IV site and the IV tubing and fluid are
on the floor. The PN immediately applies a dressing to stop the bleeding. WHAT ACTION SHOULD THE PN TAKE
NEXT? - ANSWER-Enter computer documentation of the findings and the application of a dressing.
During report, the PN is told that a client has 4+ pitting edema of both feet and ankles. The PN observes the
client's lower extremities and finds 2+ pitting edema b/l. WHAT ACTION SHOULD THE PN TAKE? - ANSWER-
Enter computer documentation of the finding.
The UAP working in a small community hospital obtains 0800 V/S measurements of clients on the unit. In
reviewing these vital signs, WHICH MEASUREMENT WARRANTS IMMEDIATE INTERVENTION BY THE NURSE? -
ANSWER-A one-month old infant with a HR of 80 bpm.
The nurse is assigned to care for four children. WHICH CHILD SHOULD BE ASSESSED FIRST? - ANSWER-18 month
old who has cystic fibrosis and is wheezing.
On a short-staffed unit of a long-term are facility, it is most important that the nurse assign the UAP to
complete this morning care for the resident with which problem first? - ANSWER-Frequent episodes of fecal
incontinence.
,Which client should the nurse assess first? - ANSWER-A client who is ambulating with partial weight-bearing
after a total hip replacement.
After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse's immediate
intervention? The client who is: - ANSWER-Trembling and has a glucose level of a 50 mg/dL.
The PN who is working as the charge nurse at an extended care facility is making assignments for the UAP
working a 12-hour shift. WHICH RESOURCE IS MOST IMPORTANT IN GUIDING THE PN's assignments of the
UAPs? - ANSWER-The state's Nurse Practice Act regarding delegation to unlicensed personnel.
In caring for a client following a BKA, WHICH TASK IS BEST FOR THE NURSE TO DELEGATE TO THE UAP who is
assisting with the care of this client? - ANSWER-Empty and measure the drainage in the suction drainage
device.
Which client should the nurse assign to a UAP? - ANSWER-A client who has a regular HR after a pacemaker
replacement and now needs to ambulate.
Which task could the nurse safely delegate to the UAP? - ANSWER-Oral feeding of a two-year-old child after
application of a hip spica cast.
The nurse assigns a UAP to feed a client who is at risk for aspiration. To ensure that the task is safely delegated,
WHAT ACTION SHOULD THE NURSE IMPLEMENT? - ANSWER-Observe the UAP's ability to implement
precautions during feeding.
The nurse is in charge of a nursing unit in a long term care facility. WHICH TASK IS BEST FOR THE NURSE ASSIGN
TO A UAP who is helping with the care of SEVERAL clients? - ANSWER-Cleanse the perineal area of client with
urinary incontinence.
After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial
decubiti dressing with a diarrheal stool. WHAT ACTIVITY IS BEST FOR THE NURSE TO ASSIGN TO THE UAP? -
ANSWER-Provide perianal care and collect clean linens for the dressing change.
, A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse
identifies that a UAP has omitted a vital component of the protocol. AFTER IMPLEMENTING THE MISSING
COMPONENT, WHAT ACTION SHOULD THE PN TAKE? - ANSWER-Supervise the UAP after reviewing the
protocol.
The nurse asks a UAP for feedback about an assigned client. Instead of responding, the UAP walks away from
the nurse, ignoring the question. WHAT ACTION IS THE BEST FOR THE NURSE TO TAKE? - ANSWER-Approach
the UAP to discuss the behavior and obtain the information needed about the client.
The principles of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of
the client? - ANSWER-A nuriewho translates completes for a Spanish-speaking client to the HCP during rounds.
A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her
mother. WHAT RESPONSE SHOULD THE NURSE TAKE? - ANSWER-Ask for a description of what happened during
the night.
A female client complains to the nurse about being admitted to a semi-private room and expresses her
displeasure because she requested a private room prior to admission. WHAT RESPONSE IS BEST FOR THE
NURSE TO PROVIDE TO THIS CLIENT? - ANSWER-Your healthcare provider must provide a written request to get
you a private room.
Which nurse's behavior is a breach of client confidentiality according to the Health Insurance Portable
Accountability Act (HIPPA) regulations? - ANSWER-A daily report sheet with the information of the team's
clients is taken home.
The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff
member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal
cancer. WHAT IS THE BEST NURSING ACTION? - ANSWER-Approach the individuals involved and ask them to
stop.
A terminally ill client and his family are requesting hospice care after discharge from the hospital an ask the
nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy
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