Fundamentals - HESI : PN 2023 Questions And Answers

A client is undergoing chemotherapy treatment and has a decreased neutrophil count. The client is under protective (reverse, or neutropenic) precautions. While the nurse is caring for the client, the client hands her cell phone to the nurse and says, “This is my pastor, can you explain to him about this isolation stuff?” Which comments are most appropriate for the nurse to make?
(Select all that apply.)
a. “Her white blood cells are dangerously low right now.”
b. “She would probably enjoy visits from your preschool choir.”
c. “If her white blood cells drop any further, she will be on isolation a long time.”
d. “I think she would benefit from members of the congregation phoning her.”
e. “She can communicate with others via email or texting.”
f. “Could you send her flowers from your congregation?”
D) “I think she would benefit from members of the congregation phoning her.”
E) “She can communicate with others via email or texting.”
Rationale:
A client under protective (reverse or neutropenic) precautions due to an increased risk of infection due to a low neutrophil count. The client can communicate with others via phone, email or texting. The client cannot have visits from children, and cannot have flowers or plants in the room, due to a risk of infection. It is a violation of client privacy rights to discuss the client’s white blood cells counts. The client asked the nurse to provide information about the precautions in place, not her white blood cells.
Which client finding requires further action by the practical nurse (PN)?
a. A disoriented client’s soft wrist restraints are tied to the bed frame.
b. The drainage tube of an indwelling catheter is looped below the client’s bladder.
c. The aspirant of a client’s nasogastric tube has a pH of 4.
d. Skin over the coccyx blanches when the client is repositioned to a lateral position.
B) The drainage tube of an indwelling catheter is looped below the client’s bladder.
Rationale:
Urine collecting in a loop of tubing that is dependent will not drain properly and places the client at risk for infection, so the (PN) should reposition the urinary drainage tube to eliminate looping below the bladder.
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An older adult client has been diagnosed with Clostridium difficile (C. Diff)–associated diarrhea. Which is the best method to prevent transmission of the disease to other clients in the long-term care facility?
a. Adequate handwashing with soap and water
b. Conducting cultures of all the employees’ stools
c. Asking staff members to stay home if they develop diarrhea
d. Installing alcohol based hand sanitizer inside each client’s door
A) Adequate handwashing with soap and water
Rationale:
The organism that causes C. Diff–associated diarrhea is not killed by alcohol-based hand sanitizers. Adequate handwashing with soap and water is the best way to prevent the spread of the disease since it helps remove most of the microorganism on the hands of staff members. Employees should stay home if they develop diarrhea, but this is not specific to C. Diff–associated diarrhea. Collecting stool samples from employees would not stop the spread of the disease.
The nurse is shopping at a mall when an individual with a large machete suddenly starts stabbing other shoppers. Security police have captured the assailant. Multiple shoppers and mall employees immediately left the premises. Which victim should the nurse attend first until first responders arrive?
A) An individual whose head is completely severed.
B) An individual with a pulsating gash to the forearm.
C) An individual whose ankle was twisted running from the scene.
D) An individual who has no palpable pulse and no respiratory effort.
B) An individual with a pulsating gash to the forearm.
Rationale:
The nurse should attend to the individual with a pulsating gash to the forearm. It is likely the nurse can slow the bleeding by applying direct pressure or a tourniquet to the arm. The individual whose head is completely severed is dead. The individual who has no pulse would require a great deal of resources while the individual whose arm is severed could be attended to by one individual. The individual with a twisted ankle can be treated at a later time.
The practical nurse (PN) is performing nasotracheal suctioning. After the client’s trachea is suctioned for 10 seconds, large amounts of thick yellow secretions return. What action should the PN implement next?
a. Encourage the client to cough to help loosen secretions.
b. Advise the client to increase intake of oral fluids.
c. Rotate the suction catheter to obtain any remaining secretions.
d. Reoxygenate the client before attempting to suction again.
D) Reoxygenate the client before attempting to suction again.
Rationale:
Suctioning should not be continued for longer than 10 seconds because the client’s oxygenation is compromised during this time.
While performing colostomy care, the practical nurse (PN) observes skin irritation around the stomal site. What action should the PN take when reapplying the colostomy bag?
a. Ensure that the hydrocolloidal stomal wafer covers the peristomal skin.
b. Apply petroleum jelly around the stomal site and under the wafer.
c. Do not irrigate the colostomy for 7 to 10 days until irritation is gone.
d. Wash the area around the stomal site with povidone-iodine and leave open to the air.
A) Ensure that the hydrocolloidal stomal wafer covers the peristomal skin.
Rationale:
*Hydrocolloid stomal wafers should be measured precisely to ensure peristomal skin coverage and protection from irritation and breakdown.
*The stomal site should be cleansed gently with a moist, soft cloth and mild soap and another bag applied to prevent skin contact with fecal drainage.
Before performing a fecal occult blood test or guaiac test on a stool specimen, the practical nurse (PN) should ask the client about the regular use of which vitamin?
a. A
b. B1
c. C
d. D
C) C
Rationale:
The guaiac test measures microscopic amounts of blood in feces. A false-positive result can occur from the regular use of vitamin C.
The nurse has just begun a sterile wound dressing change for a resident at a long-term care facility when the nurse’s pager goes off, indicating a health care provider is calling the nurse with prescriptions for a different resident. What should be the nurse’s action?