Question

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and unlicensed assistive personnel Which task should the nurse assign to the

Answer 1

Correct Answers:

Titrate Oxygen to prescribed parameters.

Rationale :

🔷 Titrating oxygen based on prescribed parameters is within the scope of a practical nurse (PN), as it follows a defined protocol.

🔷 PNs are trained to adjust oxygen flow rates based on specific provider orders without requiring a new assessment.

🔷 This task does not involve independent clinical decision-making or complex assessment, which are RN responsibilities.

🔷 The RN retains tasks such as initial assessment and plan of care development, not suitable for delegation to a PN.

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Answer 2

Correct Answers:

This hernia is a normal variation that resolves without treatment.

Rationale :

🔶 Umbilical hernias in infants are usually benign and self-resolving by age 1–2 years.

🔶 No treatment is typically required unless the hernia persists past early childhood or causes complications.

🔶 Applying a quarter or other objects may pose infection or skin injury risk and should be discouraged.

🔶 Parental education is key to reduce anxiety and prevent harmful home remedies.

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Answer 3

Correct Answers:

Reassure the client that skin flushing is a common side effect of the medication.

Rationale :

💠 Tadalafil (Cialis) often causes benign side effects like facial flushing, nasal congestion, or headache.

💠 The client's lack of chest pain and stable angina history indicates no acute cardiac event.

💠 Emergency care is not required unless accompanied by severe or unusual symptoms.

💠 Reinforcing medication education promotes safe self-monitoring and reduces unnecessary anxiety.

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Answer 4

Correct Answers:

A 30-year-old depressed client who admits to suicide ideation.

Rationale :

💎 Clients with suicidal ideation require comprehensive mental health assessments and safety interventions by an RN.

💎 This client is at high risk for harm, requiring advanced clinical judgment and potential coordination of psychiatric care.

💎 The other clients, while needing care, are more stable or suited to PN-level responsibilities.

💎 Mental health safety planning and monitoring fall under RN responsibilities.

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Answer 5

Correct Answers:

Hemoglobin

Rationale :

⬖ Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) known to cause GI bleeding and ulcers.

⬖ Stomach pain, weakness, and fatigue suggest possible blood loss and anemia.

⬖ Monitoring hemoglobin evaluates for internal bleeding and informs decisions on treatment adjustments.

⬖ Prompt lab testing can prevent worsening outcomes, especially in elderly or high-risk clients.

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Answer 6

Correct Answers:

Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM).

Rationale :

Obtain postoperative vital signs for a client one day following unilateral knee

✅ Monitoring vital signs is a routine task that falls well within the scope of a practical nurse (PN).

✅ On postoperative day one, the client is generally stable, and this assessment requires basic clinical judgment but no complex decision-making.

✅ This task is critical for identifying trends in post-op recovery and ensures ongoing surveillance for complications.

✅ Delegating this task to the PN allows the RN to focus on more acute or complex care activities.

Perform daily surgical dressing change for a client who had an abdominal hysterectomy

✅ Surgical dressing changes are appropriate for a PN when the wound is stable and instructions are clear.

✅ The PN can perform sterile procedures like dressing changes as long as assessments requiring RN judgment are not needed.

✅ Routine wound care helps prevent surgical site infections, and timely care supports proper healing.

✅ Delegating this task to the PN helps maintain continuity of care and proper wound surveillance.

Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)

✅ Administering subcutaneous insulin based on a sliding scale is a medication administration task within PN scope.

✅ PNs are trained to recognize blood glucose values and administer medications accordingly using pre-established guidelines.

✅ This task does not involve adjusting the insulin regimen independently, which would require RN-level clinical decision-making.

✅ It ensures timely glucose management, an essential part of diabetes care in the hospital setting.

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Answer 7

Correct Answers:

Reposition the infant every 2 hours.

Rationale :

⬘ During home phototherapy, repositioning every 2 hours ensures maximum skin exposure to light.

⬘ Proper exposure helps in reducing bilirubin levels efficiently and safely.

⬘ Prevents pressure injuries and uneven treatment due to prolonged positioning.

⬘ Other measures like frequent feeding support bilirubin excretion, but light exposure is the primary therapy.

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Answer 8

Correct Answers:

Reassure the client that skin flushing is a common side effect of the medication.

Rationale :

⬙ Tadalafil, a PDE-5 inhibitor, often causes transient flushing due to vasodilation.

⬙ The client has no current chest pain or signs of emergency, making reassurance appropriate.

⬙ Educating the client on expected effects versus warning signs helps prevent misuse of emergency resources.

⬙ The nurse should advise avoiding nitrates due to risk of dangerous hypotension with PDE-5 inhibitors.

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Answer 9

Correct Answers:

Avoid urinary catheterization.

Rationale :

◈ Prostatitis involves inflammation of the prostate, often bacterial, and catheterization may worsen infection.

◈ Inserting a catheter can introduce or exacerbate infection and cause trauma in inflamed tissue.

◈ The nurse should direct the PN to monitor voiding and encourage fluid intake instead.

◈ Avoiding catheter use is a standard part of prostatitis symptom management and infection control.

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Answer 10

Correct Answers:

Observe insertion site.

Rationale :

❖ For a suprapubic catheter, assessing the insertion site is essential to detect signs of infection or leakage.

❖ The site must be clean, dry, and free of redness or drainage to indicate proper healing.

❖ Ongoing inspection is part of routine catheter care during home health visits.

❖ Ensuring site integrity reduces the risk of ascending urinary tract infections.

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RN HESI Exit~2025 Exam 2

No.

1 :
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and unlicensed assistive personnel Which task should the nurse assign to the

2 :
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

3 :
A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

4 :
The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

5 :
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

6 :
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

8 :
A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

9 :
The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding the care of this client?

10 :
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

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RN HESI Exit~2025 Exam 2

No.

1 : The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and unlicensed assistive personnel Which task should the nurse assign to the

2 : A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

3 : A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

4 : The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

5 : A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

6 : The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

8 : A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

9 : The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding the care of this client?

10 : Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

1 :
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and unlicensed assistive personnel Which task should the nurse assign to the

2 :
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

3 :
A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

4 :
The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

5 :
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

6 :
The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

8 :
A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

9 :
The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding the care of this client?

10 :
Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?