HESI PN FUNDAMENTALS PROCTORED EXAM
VERSION 6
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.Which of the following heart sounds should the nurse document?Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?Place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?Identify the client using two identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?Administer analgesics to the child on a routine schedule throughout the day and night.
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?The involvement of the client in planning the change
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.Which of the following actions by the newly licensed nurse requires intervention?Obtaining cotton balls for the tracheostomy care A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?Raise the level of the bed
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?The signature on the preoperative consent form is the client's 1 / 2
A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?Perform hand higiene
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?"What worries you about being without your teeth?"
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?"I keep having nightmares about my upcoming surgery."
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?Obtain client information
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?Remove the restraints one at a time A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?Temperature A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect?Absent bowel sounds with distention
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?"Tell me what I can do to help you overcome your fear of giving yourself injections."
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed?Lock the wheels on the bed and stretcher
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