Question

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

Answer 1

Correct Answers:

Determine if the medication is compatible with the solution.

Rationale :

🧪 Before administering any liquid medication via a feeding tube, it is essential to check if the medication is compatible with the enteral feeding solution to prevent interactions, clogging, or reduced effectiveness.

🧪 Some medications may bind with enteral formulas or require a specific timing around feedings (e.g., 30 minutes before or after).

🧪 Incompatible drugs can cause tube occlusion, altered drug absorption, or even gastrointestinal side effects.

🧪 Verifying compatibility is a critical safety step before administration and must be done even if the dose or timing is correct.

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Answer 2

Correct Answers:

Inquire if the distress could lead to considering suicide as an option.

Rationale :

🔴 The client expresses hopelessness, self-deprecation, and statements like "I do not know how much longer I can live this way," which are red flags for suicidal ideation.

🔴 Assessing suicidal risk is the highest priority, as it involves safety and life preservation.

🔴 The PN must ask direct, nonjudgmental questions about suicidal thoughts to determine if further crisis intervention or referral is needed.

🔴 Clients with OCD are at increased risk for depression and suicide, especially when symptoms are severe and life-disrupting.

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Answer 3

Correct Answers:

Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative

Rationale :

🛏️ The client’s behavior suggests postoperative delirium, which is common in older adults due to factors like anesthesia, pain, unfamiliar environment, or sleep disruption.

🛏️ Raising the side rails ensures safety without applying physical restraints, which should be avoided unless absolutely necessary.

🛏️ Notifying the family to come provides emotional support and may help calm and reorient the client through familiar presence and communication.

🛏️ This intervention promotes non-pharmacologic de-escalation, patient dignity, and encourages family involvement in care.

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Answer 4

Correct Answers:

Palpate the rate and volume of the pulse.
Measure body weight at the same time daily
Observe the color and amount of urine

Rationale :

💓 A. Palpate the rate and volume of the pulse

💓 In fluid volume excess, the heart works harder to circulate the extra volume, leading to a bounding or increased-volume pulse.

💓 The PN should palpate pulses to assess for fullness, rate, and rhythm, which may reveal signs of cardiovascular strain or overload.

💓 A fast, bounding pulse may indicate the heart is compensating for circulatory congestion, often seen in fluid overload states like heart failure or renal dysfunction.

⚖️ C. Measure body weight at the same time daily

⚖️ Daily weights are one of the most sensitive indicators of fluid volume status.

⚖️ A sudden weight gain (e.g., 2–3 pounds in 24 hours) often reflects fluid retention, not fat accumulation.

⚖️ It is essential to measure weight at the same time, on the same scale, and in similar clothing for consistency.

⚖️ This helps detect early signs of fluid overload before symptoms worsen.

💧 D. Observe the color and amount of urine

💧 In fluid overload, the kidneys may produce either increased dilute urine (if functioning properly) or decreased urine (in cases of renal compromise).

💧 Urine that is pale and copious may reflect the body’s effort to excrete excess fluid, whereas dark or scant urine may suggest renal involvement or retention.

💧 Monitoring urine helps evaluate fluid balance, renal perfusion, and ongoing fluid management.

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Answer 5

Correct Answers:

Consult with the charge nurse about the catheter.

Rationale :

🟨 A #18 catheter with a 30 mL balloon is too large for a typical adult female, especially one weighing only 50 kg, as this size and balloon volume are more appropriate for postoperative irrigation or males with prostate issues.

🟨 The standard catheter size for adult females is usually #14 or #16 with a 10 mL balloon, which reduces trauma and discomfort.

🟨 The PN should clarify the appropriateness of the catheter size before proceeding, as using an incorrect size could result in urethral injury or retention issues.

🟨 Patient safety and correct equipment selection require first confirming with the charge nurse before continuing.

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Answer 6

Correct Answers:

Begin frequent feedings of breast milk or formula

Rationale :

🍼 A glucose level of 40 mg/dL (2.2 mmol/L) is within the low-normal range but concerning, especially since the infant is jittery, which is a clinical sign of neonatal hypoglycemia.

🍼 The first-line intervention for mild to moderate hypoglycemia in a stable neonate is to initiate early and frequent feeding with breast milk or formula, which provides a natural source of glucose.

🍼 Infants born to mothers with gestational diabetes are at risk for hyperinsulinemia, which increases glucose utilization and can cause rapid postnatal hypoglycemia.

🍼 Starting feeds promptly helps stabilize glucose levels, support growth, and reduce the need for IV glucose unless the hypoglycemia worsens.

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Answer 7

Correct Answers:

Weigh every morning.

Rationale :

⚖️ In chronic kidney disease (CKD), the kidneys cannot efficiently excrete fluid and waste products, leading to fluid retention, hypertension, and electrolyte imbalances.

⚖️ Daily weight is a critical assessment because a sudden increase may signal fluid overload, which can worsen blood pressure and neurologic symptoms such as confusion or altered mental status.

⚖️ Weighing every morning under consistent conditions helps the healthcare team track fluid shifts and adjust diuretics, dialysis timing, or fluid restrictions accordingly.

⚖️ This intervention is essential to monitor and manage disease progression and prevent complications.

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Answer 8

Correct Answers:

Small gauze pad.
Paper tape.
Exam gloves.

Rationale :

✅ A. Small gauze pad

✅ A sterile or clean small gauze pad is essential for applying immediate pressure to the catheter insertion site once the saline lock is removed.

✅ This helps to control bleeding and protects the site while clotting occurs.

✅ After pressure is applied and bleeding is stopped, the gauze serves as a protective barrier over the site until it is sealed.

✅ It is also useful in maintaining site cleanliness and reducing the risk of local infection or irritation.

✅ B. Paper tape

✅ Paper tape is used to secure the gauze dressing over the site after catheter removal.

✅ It is hypoallergenic and gentle on the skin, making it especially appropriate for clients with fragile, elderly, or sensitive skin.

✅ Paper tape ensures the dressing remains intact and immobile, preventing contamination or dislodgment.

✅ It also allows for easy removal without skin trauma during dressing changes or follow-up inspection.

✅ D. Exam gloves

✅ Non-sterile exam gloves are required to maintain standard precautions during the procedure.

✅ Gloves protect the nurse from exposure to blood and body fluids, which is a common risk when removing any vascular access device.

✅ They also protect the client by helping to prevent contamination of the insertion site, especially since this is a clean, but not sterile procedure.

✅ Wearing gloves ensures compliance with infection control policies and universal precautions.

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Answer 9

Correct Answers:

Remind the client what day of the week it is.

Rationale :

🧠 A sudden, mild confusion in an older adult within 24 hours of admission may be due to relocation stress syndrome, environmental change, or mild delirium.

🧠 The most appropriate nursing response is to provide orientation cues, such as reminding the client of the day, place, and situation, which helps reduce confusion.

🧠 Orientation aids like calendars, clocks, and gentle reminders support cognitive function and can prevent worsening confusion.

🧠 Early and supportive reorientation is both a non-invasive and therapeutic approach.

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Answer 10

Correct Answers:

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

Rationale :

🌬️ The child's symptoms — increased irritability, tachypnea, and resting stridor — indicate worsening airway obstruction, which is a hallmark of moderate to severe croup.

🌬️ Pulse oximetry provides a non-invasive, real-time assessment of the child's oxygenation status, which is critical for early detection of hypoxia.

🌬️ Monitoring SpO₂ allows the PN to identify if intervention (e.g., oxygen therapy or escalation to emergency care) is needed promptly.

🌬️ Croup can progress rapidly, so assessing and tracking oxygenation is the most important immediate action to ensure safety.

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PN Hesi Exit-2025 Exam 1

No.

1 :
The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

4 :
Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

5 :
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

7 :
A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

8 :
The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

9 :
An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

10 :
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?

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PN Hesi Exit-2025 Exam 1

No.

1 : The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

4 : Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

5 : The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

7 : A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

8 : The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

9 : An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

10 : 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?

1 :
The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

4 :
Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

5 :
The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?

7 :
A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

8 :
The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

9 :
An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

10 :
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?