Question

The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

Answer 1

Correct Answers:

Document the capillary refill time.

Rationale :

⭐ Verifying new prescriptions ensures that all urgent treatments and medications are addressed without delay.

⭐ Missed or delayed prescriptions can compromise client safety, making this the top priority before shift handover.

⭐ This action directly impacts continuity of care, ensuring clients’ immediate needs are not overlooked.

⭐ Tasks like organizing, charting, or I&O calculation are important but not time-sensitive compared to verifying new orders.

⭐ This aligns with the safety and priority principle in nursing (ABCs & Maslow’s hierarchy).

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Answer 2

Correct Answers:

0.6

Rationale :

🔹 Daily dose = 30 mg q12h → 60 mg/day.

🔹 Available: 30 mg/0.3 mL, so set up proportion: 30 mg : 0.3 mL = 60 mg : X mL.

🔹 Cross multiply: 30x = 18 → x = 0.6 mL.

🔹 Accurate calculation prevents under/overdosing, critical with anticoagulants.

🔹 Visual proportion setups aid comprehension for med calc questions.

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Answer 3

Correct Answers:

Suction the trachea.

Rationale :

♦ Seizures increase risk of aspiration due to pooled secretions or emesis.

♦ Suctioning clears the airway and prevents hypoxia, which is life-threatening.

♦ Having equipment at bedside ensures rapid response when seizures occur.

♦ Other equipment like restraints or NG tubes are not standard seizure precautions.

♦ Airway protection is always the first priority during seizure management.

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Answer 4

Correct Answers:

Children need time to actively explore their environment.

Rationale :

✅ Prednisone irritates the gastric lining and can cause GI upset if taken on an empty stomach.

✅ Food buffers the stomach and enhances absorption of corticosteroids.

✅ Teaching correct administration reduces non-compliance and complications.

✅ Clients must understand that prednisone is not “as needed” but scheduled therapy.

✅ This teaching prevents avoidable side effects like ulcers or gastritis.

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Answer 5

Correct Answers:

"It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready."

Rationale :

🌟 This response demonstrates therapeutic communication, respecting the client’s readiness to cope with body image changes.

🌟 Allowing the client to process feelings at her own pace avoids forcing premature confrontation with the incision.

🌟 The nurse’s availability conveys support, empathy, and presence, which helps build trust in the nurse-client relationship.

🌟 Clients recovering from mastectomy often experience grief and loss, and acknowledgment without pressure facilitates healthy emotional adjustment.

🌟 Forcing acceptance or minimizing feelings (as in other options) may increase resistance and emotional distress.

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Answer 6

Correct Answers:

Administer the medication and document the heart rate.

Rationale :

💎 For infants, the safe apical heart rate parameter before giving digoxin is generally >90–100 beats/minute.

💎 A heart rate of 120 beats/minute in a 2-month-old is within the normal range (100–160 bpm for infants).

💎 Since the infant’s heart rate is not bradycardic, the dose should not be withheld.

💎 Documentation of the pre-administration heart rate ensures adherence to safe medication administration protocols.

💎 Holding the medication unnecessarily could risk worsening the infant’s cardiac output if digoxin therapy is interrupted.

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Answer 7

Correct Answers:

Health care proxy documentation.

Rationale :

🔷 Admission assessment for a terminally ill client focuses on advance directives and decision-making authority.

🔷 Health care proxy documentation identifies the person legally authorized to make healthcare decisions if the client is unable.

🔷 This ensures that all treatment decisions align with the client’s values and preferences.

🔷 While organ donation and funeral arrangements are important, they are not the immediate priority at admission.

🔷 Confirming proxy documentation helps the healthcare team respect ethical and legal standards in end-of-life care.

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Answer 8

Correct Answers:

Ability to swallow.

Rationale :

🟡 Stomatitis is inflammation of the oral mucosa, often causing pain, swelling, and ulcerations.

🟡 The primary concern is whether the client can safely swallow food and fluids without aspiration or severe discomfort.

🟡 Difficulty swallowing may lead to nutritional deficits, dehydration, and weight loss, making it the most relevant assessment focus.

🟡 Monitoring swallowing ability also guides the need for dietary modifications such as soft or liquid diets.

🟡 Other parameters like urinary output, bowel movements, or standing blood pressure are not directly related to stomatitis.

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Answer 9

Correct Answers:

Tell the client that the PN will verify that the dispensed medication is the valid prescription.

Rationale :

⭐ This response prioritizes client safety by ensuring the correct medication is administered.

⭐ Verifying the medication demonstrates accountability and professionalism, reducing the risk of medication errors.

⭐ It also builds trust with the client, showing that their concerns are taken seriously.

⭐ Clients are often the best source to detect potential discrepancies since they are familiar with their home medications.

⭐ Explaining substitutions or assuming confusion before verification may lead to unsafe administration or patient mistrust.

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Answer 10

Correct Answers:

Electrolytes

Rationale :

🔶 Numbness and tingling (paresthesia) often result from abnormal levels of electrolytes such as calcium, potassium, and sodium.

🔶 Low calcium can cause neuromuscular irritability and tingling around the mouth or extremities.

🔶 Abnormal potassium levels affect nerve conduction and muscle function, leading to paresthesia.

🔶 Prompt reporting allows for early intervention to prevent complications such as arrhythmias or seizures.

🔶 While hematocrit, albumin, and WBC are important, they do not directly explain the neurological symptoms of tingling.

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Hesi PN Exit~2024 Exam 3

No.

1 :
The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

3 :
In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

4 :
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

5 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best

6 :
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

7 :
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

8 :
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

9 :
A male client tells the practical nurse (PN) that the pill he has been taking at home is a diﬀerent color and size than the one the PN is trying to give him now. How should the PN respond?

10 :
A client reports experiencing numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) prioritize reporting to the healthcare provider?

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Hesi PN Exit~2024 Exam 3

No.

1 : The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

3 : In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

4 : The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

5 : At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best

6 : Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

7 : Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

8 : The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

9 : A male client tells the practical nurse (PN) that the pill he has been taking at home is a diﬀerent color and size than the one the PN is trying to give him now. How should the PN respond?

10 : A client reports experiencing numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) prioritize reporting to the healthcare provider?

1 :
The practical nurse (PN) applies and then releases pressure to a client's fingernail as seen in the photo. Normal nail color returns in 2 seconds. Which action should the PN take?

3 :
In caring for a client who requires seizure precautions, the practical nurse (PN) should ensure the ready availability of equipment to perform which procedure?

4 :
The practical nurse (PN) is told that she keeps her 2-year-old child in a playpen so he will not get dirty. Which statement should the PN use in responding to this concern about using a playpen?

5 :
At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best

6 :
Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, what action should the PN take?

7 :
Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

8 :
The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

9 :
A male client tells the practical nurse (PN) that the pill he has been taking at home is a diﬀerent color and size than the one the PN is trying to give him now. How should the PN respond?

10 :
A client reports experiencing numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) prioritize reporting to the healthcare provider?