HESI PN COMPREHENSIVE PREDICTOR EXAM

HESI PN COMPREHENSIVE PREDICTOR EXAM

VERSION 12

• A client begins treatment with phenytoin (Dilantin). Which following should the nurse

reinforce as a measure to help minimize possible adverse effects of this medication?

• Performing daily gum massage

• A nurse who is facilitating a support group notices that one client in the group is

extremely talkative, to the point where others in the group have difficulty sharing their own ideas. Which of the ff. strategies should the nurse use to facilitate the group process with this client?

• Speak privately to the client about this behavior.
• The partner of a client who died from leukemia tells a nurse, ―It‘s so unfair that God took

him from me. I just can‘t live without him.‖. Which of the following actions by the nurse is the priority?

• Ask the client she has had suicidal thoughts.
• A nurse is preparing to remove a client‘s peripheral IV catheter. Which of the following

actions should the nurse plan to take?

• Maintain the catheter parallel to the vein when withdrawing the catheter.
• A nurse is reinforcing teaching to the parents of a newborn who has a new prescription

for nystatin (Mycostatin) for oral candidiasis. Which of the following should the nurse include in the teaching?

• Instill the medication 1 hr. after feeding.
• A nurse is reinforcing teaching about an IV urography (IVP) with the parent of a 3yr. old

child. Which of the ff. statements indicates the parent understands the teaching?

• My child will need to have a soapsuds enema before this procedure.
• A nurse is reinforcing teaching with the parent of a school-age child who has nephrotic

syndrome with peripheral edema. Which of the ff. statements by the parent indicates understanding of the teaching?

• I will provide a low-sodium diet for my child.
• A nurse is caring for a client who is on complete bed rest and is unable to change positon

in bed without assistance. The nurse delegates the task of repositioning the client every 2 hr. to an assistive personnel(AP). Which of the ff. is an appropriate method to ensure that the AP has performed the task correctly?

• Check that the client is in a new position every 2hr.

• A newly hired nurse discovers that some medication doses provided on a client‘s

medication record have not been updated since yesterday. Coworkers admit that new changes in the medication orders have not been processed yet, but they advise the nurse to administer the new prescriptions anyway. The nurse should notify which of the ff.?

• The nurse manager.
• A registered nurse and a licensed practice nurse (LPN) on a medical–surgical unit are

collaborating to provide care for a group of clients. The LPN should recognize that which of the ff. tasks are not within the LPN scope of practice?

• Develop a plan of care for a client who requires bladder training.

• Which of the ff. should a nurse recognize as indicative of a positive client response to 1 / 3

systematic desensitization for treatment of a phobia?

• The client remains relaxed when thinking of the phobia.
• A nurse in a long-term care facility is reviewing standard precaution guidelines with an

assistive personnel(AP). The nurse should instruct the AP that which of the ff. should be used to clean up a blood spill?

• Chlorine bleach solution.
• A nurse is caring for a client who is 3 days postoperative ff. a transurethral resection of

the prostate and has an indwelling urinary catheter. Which of the ff. findings should the nurse expect?

• Yellow urine with red sediment.
• A nurse is preparing to administer cephalexin (Keflex) to a client when he states, ― I just

remembered that I have an allergy to penicillin. ―Which of the ff. actions should the nurse take?

• Call the provider who prescribed the medication.
• A nurse is observing a newly licensed nurse who is providing tracheostomy care for a

client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the ff. solutions to clean the inner cannula?

• Hydrogen peroxide.
• A nurse is working with an interpreter to explain a diagnostic procedure to a client who

does not speak English. Which of the ff. actions should the nurse take?

• Ensure the interpreter is culturally compatible with the client.
• A client 12 hr. postoperative cholecystectomy was given morphine 10mg intravenously

at 0700. The nurse marking rounds at 0720 should recognize which of the ff. as an adverse effect of the medication?

• Respiratory rate 10/min
• A nurse is inserting an indwelling catheter into a female client who has urinary retention.

After urine is seen in the tubing, which of the ff. actions should the nurse take next?

• Advance the catheter 2.5 to 5 cm.
• A nurse is administering morning medication to clients on the unit. A client questions the

nurse regarding a medication that she does not recognize. Which of the ff. nursing interventions should the nurse take first?

• Verify the prescription in the client‘s medical record.

• A nurse is reinforcing teaching regarding prenatal discomfort to a client who is at 20

weeks of gestation. Which of the ff. statements made by the client indicates an understanding of the teaching?

• I will wear a supportive bra overnight.
• A nurse is caring for a client who has leukemia and is experiencing stomatitis ff.

treatment. Which of the ff. is an appropriate diet selection by the nurse?

• Oatmeal and apple sauce
• A nurse is reinforcing teaching for a client who has coronary artery disease and is taking

low-dose aspirin daily. The nurse should reinforce that this medication regimen has which of the ff. therapeutic effects?

• Antiplatelet
• A nurse is discussing STIs with a group of adolescents at a health fair. Which of the ff. is

an appropriate statement?

• An infection with Neisseria gonorrhoeae may result in infertility.
• A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat

major depressive disorder. After the procedure, which of the ff. actions should the nurse take?

• Orient the client frequently.
• A nurse is contributing to the plan of care for a client who is newly diagnosed with iron

deficiency anemia. Which of the ff. should the nurse include in the client‘s diet plan? 2 / 3

• Dried beans
• A nurse working in a long-term care facility discovers a client has fallen and appears to

have injured his neck. After calling for help, which of the ff. actions should the nurse take?

• Place a rolled blanket on each side of the client‘s head.
• A nurse is reinforcing client teaching on relaxation techniques during labor. Which of

the ff. indicates a need for further client teaching?

• I will wait until I go into labor to decide if I will use hypnosis as a relaxation

technique.

• A nurse is caring for a client experiencing hypovolemic shock. Which of the ff. actions

should the nurse take?

• Elevate the clients leg.
• A nurse in a provider‘s office is auscultating the lung sounds of an older adult client and

notices small, circular burn marks on her back and trunk. Which of the ff. actions is appropriate for the nurse to take?

• Interview the client privately about the burn marks.
• A nurse is reinforcing discharge teaching with a client who has undergone vein ligation

and stripping. Which of the ff. instructions should the nurse include?

• Preform range of motion exercises
• A nurse is contributing to the plan for care for a client who has a nasogastric tube and is

receiving continuous enteral feedings. Which of the ff. should the nurse include in the plan?

• Measure the pH of gastric tube aspirate prior to administering nutrition.

• When preparing a client for an enteral feeding, a nurse notices that the pump at the

client‘s bedside is very hot to the touch. Which of the ff. actions should the nurse take?

• Unplug the equipment and remove it from the room.
• A nurse is reinforcing teaching for a client who is taking spironolactone (Aldactone).

Which of the ff. dietary choices should the client limit?

• Cantaloupe
• A nurse is caring for a client who has been prescribed amitriptyline. After 1 week, the

client calls the provider‘s office and states, ―I‘m not taking these pills anymore. They are not doing anything‖. Which of the ff. response by the nurse is appropriate?

• It may take up to 4 weeks before you feel a difference when taking this medication.
• A nurse is caring for an older adult client who had surgery for a ruptured appendix 3

days ago the client has a tube in place. Which of the ff. should the nurse do to determine whether or not peristalsis is restored?

• Auscultate for bowel sounds.
• A nurse is working in a long-term care facility. Which of the ff. actions should the nurse

take when using computer-based client records?

• Shred printouts of client care information when they are no longer needed.
• A nurse working in a community clinic is caring for an adolescent who has infectious

mononucleosis. The client the nurse to explain how the disease was acquired. The nurse explains that an individual acquires this disease which of the ff.

• Sharing eating utensils with an infected person.
• A nurse is reinforcing discharge teaching for a client who has a new colostomy. Which of

the ff. statements made by the client indicates an understanding of the teaching?

• ―I will open the bottom of the pouch to empty the contents before I remove it.‖
• A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes

mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia?

A. 1100

• A nurse in a clinic is obtaining a health history from a client scheduled to undergo a
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