Question

The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

Answer 1

Correct Answers:

Red welts widespread over the chest.

Rationale :

💠 Loratadine is a second-generation antihistamine used to treat allergic conditions such as urticaria (hives).

💠 Red welts are a common presentation of histamine-mediated skin reactions, which loratadine effectively alleviates.

💠 Unlike other signs like pustules or bruising, red welts are directly linked to allergic responses that require antihistamines.

💠 The drug has minimal sedation effect, making it ideal for daytime relief of hives and allergic rhinitis.

💠 Prompt administration helps prevent escalation to more severe reactions like angioedema or anaphylaxis.

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Answer 2

Correct Answers:

40

Rationale :

🔷 Client's finger stick glucose = 271 mg/dL, which falls in the 15-unit range on the sliding scale.

🔷 NPH insulin dose is fixed at 25 units, given before breakfast.

🔷 Total insulin

NPH (25 units) + sliding scale (15 units)

40 units.

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Answer 3

Correct Answers:

Safety plan to keep in a purse at all times.

Rationale :

🔶 A personalized safety plan empowers the client to act quickly during dangerous situations.

🔶 It includes emergency contacts, exits, and safe zones, which are essential in intimate partner violence (IPV) cases.

🔶 Keeping the plan in the purse ensures immediate accessibility, especially if escaping danger.

🔶 It encourages proactive self-protection without requiring immediate confrontation or disclosure.

🔶 Developing the plan fosters trust and control, critical for clients in abusive relationships.

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Answer 4

Correct Answers:

Ability to swallow.

Rationale :

✨ Stomatitis involves inflammation of the oral mucosa, often resulting in painful sores and ulcers.

✨ Assessing swallowing ability ensures the client can maintain nutrition and take oral meds safely.

✨ Difficulty swallowing increases the risk of aspiration, malnutrition, and dehydration.

✨ Monitoring swallowing informs the need for alternative feeding methods (e.g., soft foods, IV fluids).

✨ It's also essential for preventing further trauma to the oral mucosa.

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Answer 5

Correct Answers:

Monitor the child's oxygen saturation level via pulse oximetry.

Rationale :

🟠 Resting stridor and tachypnea indicate upper airway obstruction, which is potentially life-threatening.

🟠 Monitoring oxygen saturation helps assess respiratory compromise early.

🟠 Croup can rapidly deteriorate; saturation monitoring is key for timely escalation to oxygen or steroids.

🟠 This objective measure helps guide respiratory interventions like nebulized epinephrine.

🟠 Early detection of hypoxia prevents complications like respiratory arrest in children.

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Answer 6

Correct Answers:

Pupils reactive to accommodation.

Rationale :

🟢 This finding confirms that the pupils constrict when shifting focus from a distant object to a near object, a normal neurological reflex.

🟢 It indicates that cranial nerve II (optic) and cranial nerve III (oculomotor) are functioning properly.

🟢 The ability of the pupils to accommodate is part of a triad response: convergence, accommodation of the lens, and pupil constriction.

🟢 This documentation is essential when assessing visual reflexes and for ruling out neurological impairment.

🟢 It supports that midbrain integrity is preserved, as the reflex is mediated there.

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Answer 7

Correct Answers:

Administer the medication and document the heart rate.

Rationale :

🔵 A heart rate of 120 bpm in a 2-month-old infant is within the safe range for administering digoxin.

🔵 The therapeutic threshold for holding digoxin in infants is <90–100 bpm, so 120 is appropriate.

🔵 Administering as prescribed maintains therapeutic levels and helps treat heart failure or arrhythmias.

🔵 Proper documentation of the heart rate supports medication safety monitoring and adherence to clinical protocols.

🔵 Prompt administration prevents disruption in cardiac contractility and maintains hemodynamic stability.

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Answer 8

Correct Answers:

Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry.

Rationale :

🟣 The presence of PVCs (premature ventricular contractions) suggests electrolyte imbalance, likely hypokalemia or hypomagnesemia, common with GI losses from NG suction.

🟣 The NG suction leads to loss of H+, Na+, K+, and Cl−, contributing to metabolic alkalosis and cardiac irritability.

🟣 Early detection and reporting of arrhythmias help prevent progression to life-threatening dysrhythmias.

🟣 Even if the heart rate is within normal range, the abnormal rhythm mandates immediate attention.

🟣 These PVCs could indicate imminent cardiac compromise and require lab work and electrolyte replacement.

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Answer 9

Correct Answers:

That language is not allowed.

Rationale :

🔴 This response sets a clear and firm boundary in a professional and non-punitive manner.

🔴 It promotes appropriate behavior while considering the client's mental disability and developmental level.

🔴 It avoids reinforcing inappropriate comments and focuses on behavior redirection.

🔴 It ensures professionalism while maintaining therapeutic communication.

🔴 It avoids sarcasm or threats and respects both the nurse-client relationship and hospital policies.

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Answer 10

Correct Answers:

Administer a prescribed PRN dose of analgesic.

Rationale :

🟡 Herpes zoster causes neuropathic pain, described as burning or stabbing along dermatomes.

🟡 PRN analgesics are crucial for acute pain control, especially in early phases to reduce severity.

🟡 Pain control also supports rest and healing and can reduce the risk of developing postherpetic neuralgia.

🟡 Prompt pain relief improves quality of life and can prevent complications from unmanaged pain.

🟡 As this is prescribed and within the nurse's scope, there is no delay in implementing the order.

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Hesi PN Exit~2024 Exam 2

No.

1 :
The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

3 :
At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

4 :
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?

5 :
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

6 :
The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

7 :
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, which action should the PN take?

9 :
A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

10 :
The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?

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Hesi PN Exit~2024 Exam 2

No.

1 : The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

3 : At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

4 : 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?

5 : In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

6 : The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

7 : 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, which action should the PN take?

9 : A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

10 : The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?

1 :
The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

3 :
At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

4 :
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?

5 :
In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

6 :
The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

7 :
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, which action should the PN take?

9 :
A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

10 :
The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk. What action should the PN take?