Question

The practical nurse (PN) is changing the abdominal dressing of a client who was discharged home following a colon resection. Which information should the PN report to the healthcare provider?

Answer 1

Correct Answers:

The client reports the wound care is painful and would like a prescription for an analgesic.

Rationale :

🩹 The PN should report the client’s request for an analgesic prescription because pain after a surgical wound dressing change may require assessment and possible adjustment of pain management.

🩹 The healthcare provider should be notified when the client reports uncontrolled or inadequately managed pain, especially after a major procedure such as a colon resection.

🩹 Effective pain control promotes healing, mobility, deep breathing, and participation in recovery activities.

🩹 The PN cannot independently prescribe medication, so the request for additional pain medication must be communicated to the healthcare provider.

🩹 The nurse should assess the pain severity, characteristics, and any associated findings before reporting.

🩹 Unmanaged postoperative pain can negatively affect recovery and may indicate a need for further intervention.

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Answer 2

Correct Answers:

Identify problems from the assessment data.
Assess the result of the interventions.
Collect history, assessment data, and diagnostics.
Carry out the interventions or tasks.

Rationale :

Identify problems from the assessment data

🩺 Identifying problems is part of the diagnosis phase of the nursing process.

🩺 After collecting assessment information, the nurse analyzes the data to identify patient problems, needs, and priorities.

🩺 This step guides the development of appropriate nursing interventions.

Assess the result of the interventions

🩺 Evaluating the effectiveness of interventions is a key step in the nursing process.

🩺 The nurse determines whether the patient’s condition improved, remained the same, or requires changes in the plan of care.

🩺 Evaluation ensures that care remains safe and effective.

Collect history, assessment data, and diagnostics

🩺 Data collection is the assessment phase of the nursing process.

🩺 The nurse gathers information from the patient history, physical examination, laboratory results, and diagnostic findings.

🩺 Accurate assessment provides the foundation for identifying problems and planning care.

Carry out the interventions or tasks

🩺 Carrying out interventions is the implementation phase of the nursing process.

🩺 The nurse performs planned actions such as administering medications, providing treatments, and educating the patient.

🩺 Implementation is necessary to address identified patient problems.

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Answer 3

Correct Answers:

Review the posted mobility algorithm for client transfers.

Rationale :

🦺 The PN should review the posted mobility algorithm because it provides evidence-based guidance for safely transferring clients with limited movement.

🦺 Mobility algorithms help healthcare workers determine the safest method and equipment needed based on the client’s mobility level, strength, and ability to participate.

🦺 Using the correct transfer technique reduces the risk of falls, client injury, and healthcare worker musculoskeletal injuries.

🦺 Clients with limited mobility may require devices such as gait belts, transfer aids, or mechanical lifts depending on their condition.

🦺 The nurse should always assess the client’s ability before attempting movement or transfer.

🦺 Following facility-approved transfer procedures promotes safe, consistent care.

🦺 Therefore, reviewing the mobility algorithm is the safest action for transferring a client with limited movement.

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Answer 4

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available
Order : 5 : No answer text available
Order : 6 : No answer text available

Rationale :

🫁 Preoxygenation is performed first to increase oxygen reserves and reduce the risk of hypoxia during suctioning.

🫁 The suction machine is turned on before suction is applied to ensure the equipment is ready.

🫁 Covering the suction control with the thumb activates suction only when needed, preventing unnecessary airway trauma.

🫁 The catheter is advanced gently until resistance is met, then withdrawn slightly before applying suction to avoid injury to the tracheal mucosa.

🫁 Rotating the catheter while withdrawing allows secretions to be removed more effectively from the airway walls.

🫁 Suction should be limited to no more than 10 seconds per pass to prevent oxygen deprivation and airway irritation.

🫁 Therefore, the correct sequence is:

Preoxygenate → Turn on suction → Apply suction control → Advance catheter → Rotate catheter → Remove catheter.

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Answer 5

Correct Answers:

Up in the room for 5 minutes. Call bell within reach. Respirations 22 breaths/minute.

Rationale :

📝 B is the best documentation because it describes the client’s response to ambulation, including the activity performed, safety intervention, and an objective assessment finding.

📝 Effective nursing documentation should include specific, measurable, and objective data rather than vague statements.

📝 The statement records how long the client was active (5 minutes), confirms safety measures (call bell within reach), and provides an assessment finding (respirations 22/minute).

📝 Respiratory response after activity is important in older adults because it helps evaluate tolerance to exertion and functional status.

📝 Documentation should demonstrate whether the nursing intervention achieved the desired outcome and whether further monitoring is needed.

📝 Including safety measures also shows that appropriate fall-prevention actions were maintained after ambulation.

📝 Therefore, this entry best evaluates the client’s response to the nursing intervention.

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Answer 6

Correct Answers:

"I see that you are upset and crying."

Rationale :

💬 The statement “I see that you are upset and crying” is the most therapeutic response because it uses acknowledgment and validation of the client’s emotions.

💬 Therapeutic communication begins by recognizing the client’s feelings without judgment or trying to immediately solve the problem.

💬 This response shows empathy and encourages the client to express concerns in a safer and more open manner.

💬 The PN is acknowledging the client’s emotional state while allowing the client control over how much they want to share.

💬 Validation can help reduce anxiety, anger, and distress by showing the client that their feelings are being heard.

💬 A calm, supportive response is more likely to build trust and improve the nurse-client relationship.

💬 Therefore, the best therapeutic response is “I see that you are upset and crying.”

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Answer 7

Correct Answers:

Complete the medication administration process then assist the roommate.

Rationale :

🔒 The PN should complete the medication administration process first because medication preparation and administration require the nurse’s full attention to maintain patient safety and prevent medication errors.

🔒 Interruptions during medication administration increase the risk of errors such as giving the wrong medication, wrong dose, or wrong patient.

🔒 The roommate’s request is important, but it is not an emergency and can safely wait until the PN completes the medication task.

🔒 The PN should maintain focus while using the electronic medication administration record (eMAR) to verify and document medications correctly.

🔒 After completing the medication process, the PN can assist the roommate or delegate the task appropriately.

🔒 Safe nursing practice requires prioritizing actions that prevent immediate harm before addressing nonurgent requests.

🔒 Therefore, the PN should finish medication administration and then assist the roommate.

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Answer 8

Correct Answers

Flush the eye with warm tap water [ Inappropriate ]
Do not drive until the infection clears [ Inappropriate ]
Engage in frequent handwashing [ appropriate ]
Darken the lights in the room [ Inappropriate ]
Apply antibiotic eye drops daily as directed [ appropriate ]
Instill saline drops évery hour [ Inappropriate ]
Apply cool compresses as needed [ appropriate ]

Rationale :

Engage in frequent handwashing

👁️ Frequent hand hygiene is essential because bacterial conjunctivitis is highly contagious and can spread through contact with infected eye drainage.

👁️ The client should wash hands before and after touching the eye or applying eye medications.

👁️ Good hand hygiene reduces transmission to family members, especially since the client has young children in daycare.

Apply antibiotic eye drops daily as directed

👁️ Antibiotic eye drops are prescribed to eliminate the bacterial infection and should be used exactly as directed.

👁️ Completing the prescribed course helps prevent recurrence and reduces the risk of complications.

👁️ Proper medication use promotes faster resolution of symptoms.

Apply cool compresses as needed

👁️ Cool compresses can help reduce eye discomfort, irritation, redness, and swelling associated with conjunctivitis.

👁️ They provide symptomatic relief while the antibiotic treats the underlying infection.

👁️ Compresses should be clean and should not be shared with others.

❌ Flush the eye with warm tap water

👁️ Flushing the eye with tap water is not recommended because it may introduce additional microorganisms into the eye.

👁️ Eye cleansing should follow healthcare provider instructions, usually using prescribed solutions or clean methods.

👁️ This intervention may worsen irritation or infection.

❌ Do not drive until the infection clears

👁️ Bacterial conjunctivitis does not automatically require avoiding driving unless vision is impaired or medications affect vision.

👁️ The client’s assessment shows a clear cornea and normal pupil responses.

👁️ Driving restriction is not a routine eye-care instruction.

❌ Darken the lights in the room

👁️ Darkening the room is more appropriate for conditions involving photophobia, such as certain eye injuries or inflammation.

👁️ Bacterial conjunctivitis management focuses on infection control and comfort measures.

👁️ Reduced lighting does not treat the infection.

❌ Instill saline drops every hour

👁️ Saline drops may provide comfort, but hourly instillation is excessive unless specifically prescribed.

👁️ Overuse is unnecessary and does not treat bacterial conjunctivitis.

👁️ The client should use comfort drops only as directed.

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Answer 9

Correct Answers:

Document the time and reason for client's late medications.

Rationale :

📝 The PN should document the time the medication was actually administered and the reason for the delay because this provides an accurate legal record of care.

📝 Documentation should include objective facts, such as the client being unavailable because they were transported off the unit for a test.

📝 Accurate documentation supports continuity of care and allows other healthcare team members to understand why the medication was delayed.

📝 The nurse should avoid documenting opinions, blame, or unnecessary details.

📝 Medication administration records should reflect the actual administration time rather than the scheduled time if the medication was given late.

📝 Clear documentation helps maintain patient safety and provides legal protection for the nurse and healthcare facility.

📝 Therefore, the correct action is to document the time and reason for the delayed medication administration.

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Answer 10

Correct Answers:

Remove the condom and cleanse the penis with soapy water.

Rationale :

🚿 A condom catheter is an external urinary device placed over the penis, and daily care includes removing the device and cleansing the penis with soap and water.

🚿 Removing the condom allows the PN to assess the skin for irritation, breakdown, redness, swelling, or infection.

🚿 Proper cleansing helps prevent skin complications and urinary tract infections while maintaining hygiene.

🚿 After cleansing and drying the penis, a new condom catheter may be applied according to facility procedure.

🚿 The skin should be completely dry before reapplication to improve adhesion and prevent moisture-related skin problems.

🚿 Regular assessment is important because prolonged use of external catheters can cause skin irritation or injury.

🚿 Therefore, removing the condom catheter and cleansing the penis with soapy water is the appropriate action.

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Fundamentals hesi exam

No.

1 :
The practical nurse (PN) is changing the abdominal dressing of a client who was discharged home following a colon resection. Which information should the PN report to the healthcare provider?

2 :
Which steps are part of the problem-solving nursing process? Select all that apply.

3 :
The practical nurse (PN) is caring for a client with limited movement. Which action should the PN implement?

4 :
The practical nurse (PN) is suctioning a client's tracheostomy tube. (Arrange the steps in order from first on top to last on bottom.)

5 :
The practical nurse (PN) is assisting an older client-to ambulate to a chair. Which statement should the PN enter as computer documentation that describes the best evaluation of the client's response to the nursing intervention?

6 :
An adult client is crying and yells at the practical nurse (PN) to leave the room. Which is the most therapeutic response from the PN?

8 :
The practical nurse is re-educating client on how to manage the acute condition.

Correct Answers

9 :
The practical nurse (PN) enters the client's room to-administer medications. The PN realizes the client has already been transported off the unit for a lest, so medications will be given late. Which information should the PN document when medications are administered late?

10 :
In providing daily catheter care for a client with a condom catheter, which action should the practical nurse (PN) include?

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Assessment Finding	Inappropriate	appropriate
Flush the eye with warm tap water
Do not drive until the infection clears
Engage in frequent handwashing
Darken the lights in the room
Apply antibiotic eye drops daily as directed
Instill saline drops évery hour
Apply cool compresses as needed

Fundamentals hesi exam

No.

1 : The practical nurse (PN) is changing the abdominal dressing of a client who was discharged home following a colon resection. Which information should the PN report to the healthcare provider?

2 : Which steps are part of the problem-solving nursing process? Select all that apply.

3 : The practical nurse (PN) is caring for a client with limited movement. Which action should the PN implement?

4 : The practical nurse (PN) is suctioning a client's tracheostomy tube. (Arrange the steps in order from first on top to last on bottom.)

5 : The practical nurse (PN) is assisting an older client-to ambulate to a chair. Which statement should the PN enter as computer documentation that describes the best evaluation of the client's response to the nursing intervention?

6 : An adult client is crying and yells at the practical nurse (PN) to leave the room. Which is the most therapeutic response from the PN?

8 : The practical nurse is re-educating client on how to manage the acute condition.

Correct Answers

9 : The practical nurse (PN) enters the client's room to-administer medications. The PN realizes the client has already been transported off the unit for a lest, so medications will be given late. Which information should the PN document when medications are administered late?

10 : In providing daily catheter care for a client with a condom catheter, which action should the practical nurse (PN) include?

1 :
The practical nurse (PN) is changing the abdominal dressing of a client who was discharged home following a colon resection. Which information should the PN report to the healthcare provider?

2 :
Which steps are part of the problem-solving nursing process? Select all that apply.

3 :
The practical nurse (PN) is caring for a client with limited movement. Which action should the PN implement?

4 :
The practical nurse (PN) is suctioning a client's tracheostomy tube. (Arrange the steps in order from first on top to last on bottom.)

5 :
The practical nurse (PN) is assisting an older client-to ambulate to a chair. Which statement should the PN enter as computer documentation that describes the best evaluation of the client's response to the nursing intervention?

6 :
An adult client is crying and yells at the practical nurse (PN) to leave the room. Which is the most therapeutic response from the PN?

8 :
The practical nurse is re-educating client on how to manage the acute condition.

9 :
The practical nurse (PN) enters the client's room to-administer medications. The PN realizes the client has already been transported off the unit for a lest, so medications will be given late. Which information should the PN document when medications are administered late?

10 :
In providing daily catheter care for a client with a condom catheter, which action should the practical nurse (PN) include?