PN EXIT HESI Exam Questions And Answers Best Rated A+ Guaranteed
Success New Update 2022-2023
1. The practical nurse (PN) is observing a client self-administering a dose if subcutaneous
insulin. What step of the injection technique should the practical nurse (PN) reteach?
a. Injects air into the insulin vial to displace the dose
b. Selects the same site that was used for the previous injection
c. Inserts the needle at a 90-degree angle to the skin surface
d. Uses a circular motion when applying an alcohol pad to the site
Answer: b. Selects the same site that was used for the previous injection
Rationale: The PN should reteach the client to rotate the NOON site to a site other than the same
one used for the AM dose. Different sites used throughout the day may provide a varying rate of
absorption related to activity. Intra-site rotation is recommended for the dose used during one
specific time of the day. The other choices are acceptable techniques for subcutaneous injection
of insulin.
2. The practical nurse (PN) observes a newly hired unlicensed assistive personnel (UAP) who is
counting a client’s radial pulse as seen in the picture. Which action should the PN take?
a. Confirm accuracy of the pulse rate obtained by the UAP
b. Instruct the UAP to report any abnormal findings
c. Remind the UAP to check the clients pulse volume
d. Demonstrate the correct pulse site to the UAP (follow the thumb for the radial pulse, follow
the pinky for the brachial)
Answer: d. Demonstrate the correct pulse site to the UAP (follow the thumb for the radial pulse,
follow the pinky for the brachial)
Rationale: When checking the radial pulse, the index and middle finger should be aligned with
the thumb, for brachial pulse assessment should be aligned with the pinky finger.
3. The birth weight of an infant delivered by a woman with gestational diabetes is 10.1 pounds
(4,581 grams). The infant is jittery and has a heel stick glucose level of 40 mg/dL(2.2 mmol/L or
SI units) 30 minutes after birth. Based on this information, which intervention should the
practical nurse (PN) implement first?
a. Repeat the heel stick for glucose in one hour
b. Offer nipple feedings of 10% dextrose
c. Begin frequent feedings of breast milk or formula
d. Assess for signs of hypocalcemia
Answer: c. Begin frequent feedings of breast milk or formula
Rationale: Providing frequent feedings will reduce the infants blood glucose; we wouldn’t want
to obtain another heel stick as we want to do less invasive as possible.
4. A client consumes 8 ounces (oz) of broth, 4 oz of apple juice, 4 ounces of flavored gelati and 1
banana. During the same shift, this client receives 1 liter of IV fluid and voids 700 mL. How
many mL total oral and IV intake should the PN document on the client’s medical record? (Enter
numeric value only).
8 oz x 30 mL = 240 mL
4 oz x 30 mL = 120 mL
4 oz x 30 mL = 120 mL
1 L = 1000 mL
Answer: Total intake = 1480 mL
5. The nurse is very busy and running late with administering medications and asks the practical
nurse (PN) to administer a medication already drawn up in an unlabeled syringe. How should the
PN respond?
a. “You should know that I cannot administer the medication in this syringe”
b. “As long as the charge nurse checks the syringe, I can give the medication”
c. “Teamwork is the best approach. I will be glad to help you get caught up”
d. “I am not comfortable doing that. Is there something else I can do to help you?”
Answer: d. “I am not comfortable doing that. Is there something else I can do to help you?”
Rationale: Explaining your comfortability is always okay because you don’t want to jeopardize
your license, so offering to help with the nurse’s other workload is being. A team player.
6. The practical nurse (PN) is assigning care for a group of clients on the urology medical unit.
Which client should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that
apply.)
a. Irrigate an indwelling urinary catheter for a client with bladder suspension
b. Obtain a post-voided residual (PVR) volume
c. Empty beside drainage unit for a client with indwelling urinary catheter
d. Teach the client with fluid restrictions how to measure urine output
e. Transport a urine culture sample to the laboratory
Answer: c. Empty beside drainage unit for a client with indwelling urinary catheter
e. Transport a urine culture sample to the laboratory
Rationale: The scope of practice of UAP includes personal care such as bowel and bladder care
including intake and output measurements. Emptying urine from bedside drainage units and
transporting specimens are tasks that can be assigned to the UAP.
7. Which intervention should the practical nurse (PN) reinforce for a client with pruritis?
a. Encourage a warm sleeping environment
b. Do not take any type of tub bath
c. Discourage use of skin lubricants
d. Keep fingernails trimmed short
Answer: d. Keep fingernails trimmed short
Rationale: Keeping fingernails short with rough edges filed helps minimize excoriation from
scratching the pruritic (itch) area.
8. While administering prescription medications to an older resident in an extended care facility,
the practical nurse (PN) notices that the client is having difficulty hearing. What action is most
important for the PN to take?
a. Speak louder so the client can hear the conversation
b. Encourage the client to read the practical nurse’s lips
c. Provide written instructions about how to take medications
d. Determine if the client has had difficulty in the past
Answer: d. Determine if the client has had difficulty in the past
Rationale: In the older population, presbycusis is common and results from degenerative
changes in the ear with again and is often a gradual progressive, bilateral inability to hear,
especially high frequency sounds. Most importantly, the PN should determine if the clients
hearing problem is new or gradual, chronic condition.
9. The healthcare provider prescribes cefazolin 500 mg IM every 6 hours. The available vials
labeled, “Cefazolin 1 gram,” and the instructions for reconstitution state, “For IM use, add 2.5
mL sterile water for injection to provide a total volume of 3.0 mL.” After reconstitution, how
many mL should be administered to the client? (enter numeric value only. If rounding is
required, round to the nearest tenth.)
Answer: 1.3 mL
Rationale: 1 g = 1000 mg; 500 mg/ 1000 = 0.5; 0.5 x 2.5 mL =
1.25 rounded to nearest tenth = 1.3 mL
10. In caring for a client with Buck’s traction, the practical nurse (PN) observes that the
prescribed amount weights are hanging freely, and the traction rope is on the pulley. Which
action should the PN implement first?
a. Adjust the traction rope so it is free from the pulley
b. Place the weights on blocks to increase their stability
c. Contact the orthopedic technician to adjust the traction
d. Document that the Buck’s traction is being maintained
Answer: d. Document that the Buck’s traction is being maintained
Rationale: Weights that hang freely with ropes in the pulleys indicate the traction is correctly
applied. The PN should document the Buck’s traction is being maintained.
11. When a small fire breaks out in the kitchen of a long-term care facility, which task is most
important for the practical nurse (PN) to perform instead of assigning to a unlicensed assistive
personnel?
a. Provide blankets to each of the residents for use during evacuation
b. Identify the method for transporting and evacuating each resident
c. Close the doors to all of the residents’ rooms
d. Offer comfort care and reassurance to each resident
Answer: b. Identify the method for transporting and evacuating each resident
12. The practical nurse (PN) is caring for a client with coronary artery disease who is admitted
with intermittent chest pain. The admission laboratory results indicate elevations in troponin I
and creatine phosphokinase myoglobulin isoenzyme (CK-MB) levels. What should the PN
consider the most significant risk for this client on the second day of admission?
a. The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias
b. The client is at risk for recurrent long-term angina pain and subsequent myocardial infarction
c. The client is at risk for pulmonary embolism, and lifestyle modifications need to be
implemented
d. The lab results indicate risk factors for transient ischemic attack (TIA), and neuro-vital signs
should be monitored
Answer: a. The lab results indicate myocardial damage, and the client is at risk for cardiac
dysrhythmias
Rationale: Elevations in serum troponin 1 and CK-MB indicate myocardial cell damage which
cause an instability of the myocardial call membrane and can precipitate life-threatening cardiac
dysrhythmias that increase in the first 24-48 hours after a MI. Although the clients underlying
pathology places the client at risk for other complications, the incidence of dysrhythmias in the
immediate post-MI period is greatest.
13. The practical nurse (PN) observes hematuria in the urinary catheter drainage tubing of a
client who is receiving intravenous heparin. Which action should the PN implement first?
a. Obtain a urine specimen for urinalysis
b. Check the client’s gums for bleeding
c. Document the finding in the client’s medical record
d. Irrigate the urinary catheter with sterile normal saline
Answer: b. Check the client’s gums for bleeding
14. The practical nurse (PN) explains the 2-week dosage prescription of prednisone to a client
who has poison ivy covering multiple skin surfaces. What should the PN emphasize about the
dosing schedule?
a. Take the prednisone with meals
b. Monitor oral temperature daily
c. Return for blood glucose monitoring in one week
d. Decrease dosage daily as prescribed
Answer: d. Decrease dosage daily as prescribed
15. A client is receiving an anticonvulsant, diazepam, intravenously for status epilepticus. Which
intervention is most important for the practical nurse (PN) to implement?
a. Monitor the client’s respiratory rate and effort
b. Observe the clients’ eyes for deviation to the side
c. Record hourly blood pressures for the next 4 hours
d. Measure hourly urinary output for the next 8 hours
Answer: a. Monitor the client’s respiratory rate and effort
16. The practical nurse (PN) administers filgrastim to a client with neutropenia. The client later
complains of bone pain. Which action should the PN take?
a. Reassure the client that neutropenia often causes bone pain
b. Plan to administer the next dose at an alternate injection site
c. Offer to administer a prescribed PRN analgesic to the client
d. Prepare a variance report about the onset of pain after injection
Answer: c. Offer to administer a prescribed PRN analgesic to the client
Rationale: Medullary bone pain is a side effect of filgrastim, and the PN should offer to
administer an analgesic to provide pain relief.
17. The practical nurse (PN) is caring for a client who has been taking nonsteroidal antiinflammatory drug ibuprofen for arthritic pain. Which action will the PN include in this client
plan of care?
a. Give the medication on an empty stomach
b. Observe for signs of gastrointestinal bleeding
c. Encourage the client to wear sunblock when outside
d. Monitor the blood pressure frequently
Answer: b. Observe for signs of gastrointestinal bleeding
Rationale: A common side effect of NSAIDs is gastrointestinal (GI) distress. The PN should
observe for any signs of GI bleeding, and these should be reported immediately, and the client
should quit taking the medication.
18. The practical nurse (PN) reviews instructions for use of polyethylene glycol, a laxative, with
a client scheduled for a colonoscopy. Which instruction should the PN include?
a. Report the onset of watery diarrhea to the healthcare provider
b. Dilute the liquid medication with fruit juice to mask the flavor
c. Drink each glass of solution rapidly at regular specified time intervals
d. Drink the solution with the evening meal before the scheduled exam
Answer: c. Drink each glass of solution rapidly at regular specified time intervals
Rationale: to produce the best effect, the client should be instructed to drink each glass (240ml)
of polyethylene glycol solution rapidly and at regular intervals
19. The practical nurse (PN) notifies the healthcare provider about client information using
Situation, Background, Assessment, Recommendation (SBAR) technique. Which information
should the PN provide first?
a. A 26-year-old client
b. Intravenous fluids infusing at 75 mL/hr
c. Blood pressure is 80/48 mmHg
d. Cholecystectomy 24 hours ago
Answer: c. Blood pressure is 80/48 mmHg
20. In administering nystatin suspension to the gums of an infant with candida infection, which
approach should the practical nurse (PN) use?
a. Irrigate the infected area medicated solution after applying sterile gloves
b. Draw up the medication in a needle-less syringe which the infant can suck
c. Use a gloved finger to rub the suspension over the infected area
d. Measure the prescribed amount of solution into the infant’s bottle
Answer: b. Draw up the medication in a needle-less syringe which the infant can suck
21. When obtaining a capillary blood sample for glucose measurement, which intervention
should the practical nurse (PN) implement?
a. Grasp the subcutaneous tissue and pull upward
b. Remove any nail polish from the fingernails
c. Determine which finger was used previously
d. Apply a tourniquet above the antecubital fossa
Answer: c. Determine which finger was used previously
Rationale: Using another site than a previously accessed finger pad reduces repeated trauma to
the tissue and capillary supply in the distal finger where the blood sample is taken.
22. The practical nurse (PN) is assisting a client to cough and deep breathe following surgery. To
facilitate effective coughing, the PN should assist the client to assume which position?
a. Lying prone with the head turned to one side
b. Leaning forward over the bedside table
c. Left-lateral with pillow between flexed knees
d. Sitting on the side of bed with feet flat on the floor
Answer: d. Sitting on the side of bed with feet flat on the floor
Rationale: Sitting upright facilitates diaphragm excursion and enhances thoracic and abdominal
expansion.
23. An older female adult who was admitted 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?
a. Remind the client what day of the week it is
b. Document the client’s loss of memory in the record
c. Notify the family of the changes in the client’s condition
d. Encourage the client to rest during the day
Answer: a. Remind the client what day of the week it is
Rationale: Relocation often results in confusion among elderly clients during times of
adjustment to new surroundings. The PN should remind the client which day of the week it is
when she forgets or becomes confused. The other actions are not indicated at this time for
relocation or stress.
24. The practical nurse (PN) learns that a client who is receiving chemotherapy has developed
stomatitis. Which information should the PN obtain from the client during a focused assessment?
a. Frequency of bowel movements
b. Blood pressure while standing
c. Ability to swallow
d. Urinary output
Answer: c. Ability to swallow
Rationale: Stomatitis or inflammation of the oral mucosa can cause pain and result in difficulty
in swallowing. The PN should gather information related to the client’s ability to swallow.
25. The practical nurse (PN) is assigned to care for a client who had an endoscopic procedure in
which the local anesthetic was sprayed on the throat. Which priority action should the PN
include in the clients plan of care?
a. Instruct the client to speak
b. Inquire about a sore throat
c. Observe for belching
d. Assess the gag reflex
Answer: d. Assess the gag reflex
26. A client receives ondansetron prior to a chemotherapy treatment. How should the practical
nurse evaluate the effectiveness of the medication?
a. Determine if the client feels calm and relaxed before the treatment
b. Monitor the client for nausea and vomiting following the treatment
c. Observe the client for signs of pain or discomfort during the treatment
d. Assess for changes in vital signs during and after the treatment
Answer: b. Monitor the client for nausea and vomiting following the treatment
Rationale: Ondansetron is an antiemetic administered prior to chemotherapy to prevent posttreatment nausea and vomiting. The other actions do not evaluate the desired effect of
ondansetron.
27. When gathering data about a client with dark skin tones, which site should the practical nurse
(PN) observe?
a. Finger and toenails
b. Sclera and mucous membranes
c. Forehead and face
d. Hands and feet
Answer: b. Sclera and mucous membranes
28. An older client who had a colon resection 8 days ago is straining at stool. The practical nurse
(PN) observes sudden spillage of serosanguinous drainage from the client's wound followed by
appearance of bowel on the skin. Which complication has occurred?
a. Evisceration
b. Dehiscence
c. Hemorrhage
d. Infection
Answer: a. Evisceration
Rationale: Evisceration is the complete separation of a wound with protrusion of the viscera,
which usually occurs 7-10 days postoperatively.
29. A client who is being cared for in her home has a low serum sodium level of 125 mEq/L. To
determine the cause of this value, which information should the practical nurse (PN) request
from the client?
a. The amount of salt substitute used in meal preparation
b. The number of vegetable servings consumed daily
c. The percent of processed or canned foods eaten
d. The amount of ice chips and water consumed daily
Answer: d. The amount of ice chips and water consumed daily
Rationale: An excessively low serum sodium level (normal 135-145) may be the result of water
intoxication. The PN should evaluate the client’s daily consumption of ice or water.
30. A new protocol for fall prevention is being implemented on the medical unit. During safety
rounds, the practical nurse (PN) identifies that unlicensed assistive personnel (UAP) has omitted
a vital component of the protocol. After implementing the missing component, which action
should the PN take?
a. Supervise the UAP after reviewing the protocol
b. Report the UAP's omission to the charge nurse
c. Complete an unusual occurrence report
d. Assign the UAP to more stable clients the next day
Answer: a. Supervise the UAP after reviewing the protocol
31. Which intervention is within the scope of practice for a practical nurse (PN)?
a. Discharge teaching about newly prescribed medications
b. Presenting support options that are available to those with cancer
c. Teaching the use of a glucometer to a newly diagnosed diabetic client
d. Demonstrating deep breathing and coughing to a postoperative client
Answer: d. Demonstrating deep breathing and coughing to a postoperative client
32. An older postoperative client has the nursing diagnosis, "Impaired mobility related to fear of
falling." Which desired outcome best directs the practical nurse (PN) actions for this client?
a. The PN will place a gait belt on the client prior to ambulation.
b. The physical therapist will instruct the client in the use of a walker
c. The client will use self-affirmation statements to decrease fear
d. The client will ambulate with assistance q4 hours
Answer: a. The PN will place a gait belt on the client prior to ambulation.
33. The practical nurse (PN) is working in a cancer detection mobile clinic. Four individuals
come for screening with a complaint of hoarseness, a danger sign for cancer of the larynx. Which
client has the highest risk for development of cancer of the larynx that the PN should refer to the
healthcare provider?
a. An office manager whose mother has laryngeal cancer
b. A farmer who smokes a half pack of cigarettes daily
c. An older male who drinks a six pack of beer nightly and smokes heavily
d. An opera singer who does not smoke but drinks a glass of wine each day
Answer: c. An older male who drinks a six pack of beer nightly and smokes heavily
Rationale: Cancer of the larynx is more prevalent in older males who smoke and drink in excess
which increases the risk for this cancer.
34. A male preoperative client who has already signed the informed consent for a surgical
procedure confides to the practical nurse (PN) that he is really frightened and unsure about
undergoing the surgery. Which priority action should the PN take?
a. Remind the client that the consent has already been obtained
b. Document that the client has expressed concerns about the surgery
c. Notify the charge nurse of the client's concerns about surgery
d. Encourage the client to continue with the scheduled surgery
Answer: c. Notify the charge nurse of the client's concerns about surgery
35. An older client tells the home health care practical nurse (PN) about experiencing dizziness
when getting out of bed. Which assessment is most important for the PN to obtain?
a. Standing blood pressure
b. Oxygen saturation
c. Apical heart rate
d. Pulse deficit
Answer: a. Standing blood pressure
36. The practical nurse (PN) asks an unlicensed assistive personnel (UAP) for feedback about an
assigned client. Instead of responding, the UAP walks away from the PN, ignoring the question.
What action is best for the PN to take?
a. Approach the UAP to discuss the behavior and obtain the information needed about the client
b. Recognize that the UAP may be upset and ask someone else for the information
c. Submit an occurrence report identifying the UAP's lack of motivation to perform assigned job
tasks
d. In a private setting, ask the other nurses for feedback about the UAP's behavior
Answer: a. Approach the UAP to discuss the behavior and obtain the information needed about
the client
Rationale: Professional behavior includes maintaining channels of communication and ensuring
open and honest communication is focused directly on the related issues. The PN should
demonstrate assertiveness by approaching the UAP to discuss concerns and to obtain the
information needed to care for the client. The other approaches demonstrate passive- aggressive
behaviors which are unprofessional and not in the best interest of the client.
37. The practical nurse (PN) is caring for a client with fractured metatarsals after slamming ah
and in the car door. After administering the prescribed hydrocodone/acetaminophen for pain,
which intervention should the PN include in the client's care?
a. Assess the skin daily for areas of ecchymosis or other signs of bleeding
b. Encourage the client to resume normal activities after medication administration
c. Observe the client for involuntary movements of the lips and tongue
d. Implement ongoing assessments for signs of shallow or slow breathing
Answer: d. Implement ongoing assessments for signs of shallow or slow breathing
Rationale: The plan of care for a client who experiences musculoskeletal pain due to an injury
should include monitoring for changes at the injured site, complications, and outcomes of
analgesic medications. The PN should implement ongoing assessments for signs of shallow or
slow breathing for a client who is receiving hydrocodone/acetaminophen.
38. The practical nurse (PN) plans to use distraction techniques while a client undergoes a brief
painful procedure. Which action should the PN implement during the procedure?
a. Encourage the client to reminisce about a favorite past family event
b. Ask the client to describe the intensity of the pain being experienced
c. Describe the procedure to the client using a step-by-step approach
d. Explain the benefits of various alternative strategies in managing pain
Answer: a. Encourage the client to reminisce about a favorite past family event
Rationale: Distraction is used to direct the client’s attention to something other than the pain,
thereby reducing awareness of the pain for a good period of time. Distraction should involve an
activity that the client enjoys, such as talking about a favorite past event.
39. The practical nurse (PN) is assisting with the plan of care for a client with costochondritis
who is now experiencing increased discomfort in breathing. The client receives a prescription for
tramadol. What intervention should the PN include in the client's plan of care?
a. Ensure peak and trough serum levels are collected with the third medication dose
b. Implement ongoing assessments for signs of shallow or slow breathing
c. Examine the client for stomatitis and erosion of tooth enamel
d. Perform a daily whisper test of the client's hearing to detect symptoms of ototoxicity
Answer: b. Implement ongoing assessments for signs of shallow or slow breathing
40. A practical nurse (PN) is at the nurses' station describing her social life, sexual activities, and
alcohol drinking in a boisterous voice that might be heard by clients and visitors. What is the best
action that a peer nurse should do?
a. Report the situation to the nursing supervisor or peer review committee
b. Ask the PN to lower her voice when visitors walk by
c. Suggest going to the nurses' lounge if she needs to discuss these topics
d. Determine if the conversation was overheard by the clients
Answer: c. Suggest going to the nurses' lounge if she needs to discuss these topics
41. The practical nurse (PN) explains to a client how to obtain a sputum specimen and the client
indicates understanding the procedure. After the PN leaves the room, the client obtains the
specimen and notifies the PN. When the PN arrives to collect the specimen, it appears as seen in
the picture. What action should the PN take?
a. The PN should teach the client how to obtain a sputum specimen and if the client does not
correctly collect the specimen, then the PN should assist the client in obtaining another specimen
coughed directly into a sterile cup
b. Place a biohazard bag over the basin and seal the bag securely for transport to the lab
c. Apply gloves and place the tissue and specimen in a container for transport to the lab
d. Use a wooden applicator to place the sputum specimen in a sterile container
Answer: a. The PN should teach the client how to obtain a sputum specimen and if the client
does not correctly collect the specimen, then the PN should assist the client in obtaining another
specimen coughed directly into a sterile cup
42. The healthcare provider gives a pregnant woman a prescription for one prenatal vitamin with
iron daily and tells her that she needs to increase iron rich foods in her diet because her
hemoglobin is 8.2 grams/dl. When a list of iron rich foods is given to the client, she tells the
practical nurse (PN) that she is vegetarian and does not eat anything that "bleeds!" Which
instruction should the PN provide? (Select all that apply.)
a. Take two prenatal vitamins with iron daily
b. Increase green leafy vegetables in the diet
c. Oatmeal is a good choice for breakfast
d. Add lentils and black beans to soups
e. Eat red meat just until the anemia is resolved
Answer: b. Increase green leafy vegetables in the diet
c. Oatmeal is a good choice for breakfast
d. Add lentils and black beans to soups
Rationale: For clients who are vegetarians, green leafy vegetables are high in iron which is in
red blood cell production. The client should be encouraged to increase her intake of green leafy
vegetables, such as spinach, broccoli, kale, or other vegetarian sources of iron, such as oatmeal,
lentils, and black beans.
43. Which statement by a mature adult client with advanced prostate cancer best indicates that he
has reached a level of acceptance of his prognosis?
a. I think I've had this disease for a long time, but the doctor did not find it
b. I understand that this is a disease that occurs mostly in older men
c. I've found the support I need from my faith and family
d. I don't have any use for those who say this disease is going to win
Answer: c. I've found the support I need from my faith and family
44. A client is diagnosed with Clostridium difficile. Which action should the practical nurse(PN)
implement to prevent the spread of the organism?
a. Place a surgical mask on the client during transport
b. Wear a particulate respirator mask when in the room
c. Keep the door closed to the client's room at all times
d. Don non-sterile gloves when performing direct care
Answer: d. Don non-sterile gloves when performing direct care
45. A client who had orthopedic surgery 3 days ago complains of difficulty sleeping. Which
initial intervention is best for the practical nurse (PN) to implement?
a. Provide a cup of hot chocolate at bedtime
b. Administer a PRN prescription for pain
c. Reposition the client and provide a back rub
d. Offer the client a prescribed sleep medication
Answer: c. Reposition the client and provide a back rub
Rationale: Comfort measures, such as repositioning and a back rub, are the least invasive and
should be initiated before other interventions are implemented.
46. The practical nurse (PN) is preparing to assist an elderly client to the bathroom. The PN
knows that an elderly adult's center of gravity changes from the hips to another area of the body.
In planning to safely assist this client, the PN knows that the center of gravity for the elderly
client is in which area of the body?
a. Upper torso
b. Feet
c. Upper extremities
d. Head
Answer: a. Upper torso
47. An older client with metastatic breast cancer is experiencing shortness of breath as the result
of bilateral pneumonia. The client has a living will, and the family is requesting hospice care.
Which information should the practical nurse (PN) reinforce with the client and family regarding
hospice care? (Select all that apply.)
a. Care can be provided in the home where the client resides
b. The family should plan to make all decisions about care
c. Care focuses on comfort, dignity, and emotional support
d. Medications are only used to manage pain and symptoms
e. Instructions for care should be included in the client's living will
Answer: a. Care can be provided in the home where the client resides
c. Care focuses on comfort, dignity, and emotional support
e. Instructions for care should be included in the client's living will
Rationale: Hospice care can be provided anywhere the client loves, including the home, and
focuses on comfort, dignity, and emotional support. A living will describes the client’s desires
regarding end-of-life care, but does not provide specifics regarding hospice care. Under hospice
care, medications are used for symptom control but also for routine medical management or
treatment of medical problems, such as infection. The client should plan to make decisions, in
collaboration with family members as desired by the client.
48. The parents of a child with pre-diabetes report to the practical nurse (PN) that the child wants
to join a soccer team. What action is best for the PN to implement?
a. Recommend an increase in caloric intake to avoid excessive weight loss
b. Instruct the family about the need to adjust the insulin dose before exercise
c. Suggest a less strenuous activity to reduce the risk for dehydration
d. Reassure the parents that increased physical activity reduces the risk for diabetes
Answer: d. Reassure the parents that increased physical activity reduces the risk for diabetes
Rationale: Reassure the parents that their child playing soccer will be a good way to increase
their physical activity and reduce the risk for diabetes. Weight loss through diet and exercise is
the best approach to prevent the onset of diabetes in children with pre-diabetes.
49. The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection.
To evaluate the medication's effectiveness, which laboratory values should the PN monitor?
(Select all that apply.)
a. Sputum culture and sensitivity
b. Urinalysis
c. White blood cell count
d. Capillary glucose
e. Serum potassium
f. Prothrombin time
Answer: a. Sputum culture and sensitivity
c. White blood cell count
Rationale: Antibiotics are used to treat bacterial infections, which are accompanied by an
increase in the WBC and the Prescence of specific microorganisms in the sputum and their
sensitivity to the anti-infective is determined by sputum culture and sensitivity analysis.
50. The practical nurse (PN) is providing care for a client who is NPO after a small bowel
resection. The client's NG tube is connected to low intermittent suction. The client reports
dizziness and tingling in digits. Which assessment finding by the PN should be reported to the
healthcare provider?
a. Regular heart rate of 100 beats per minute on telemetry
b. Hyperactive bowel sounds on assessment
c. Hypoactive bowel sounds on assessment
d. Heart rate of 90 beats per minute with PVCs noted on telemetry
Answer: b. Hyperactive bowel sounds on assessment
51. A male client tells the practical nurse (PN) that the pill he has been taking at home is a
different color and size than the one the PN is trying to give him now. How should the PN
respond?
a. Explain that the healthcare provider probably prescribed a different medication while he is
hospitalized
b. Explain that the pharmacy often substitutes generic equivalents for more expensive brands
c. Tell the client that he is probably confused since being hospitalized tends to disorient clients
d. Tell the client that the PN will verify that the dispensed medication is the valid prescription
Answer: d. Tell the client that the PN will verify that the dispensed medication is the valid
prescription
Rationale: The client often is very familiar with routine medications taken at home, and the PN
should verify that the dispensed medication is indeed the drug prescribed by the healthcare
provider.
Prescriptions
Flow Sheets
Medication administration Record
52. The practical nurse (PN) is giving medications to a client who was admitted to the hospital
with a diagnosis of diabetes mellitus. After checking the fingerstick glucose at 1630. which dose
of insulin should the PN administer? (Enter numeric value only.) (Click on each chart tab for
additional information. Please be sure to scroll to the bottom right corner of each tab to view all
information contained in the client's medical record.
Answer: 8
53. While the practical nurse (PN) and unlicensed assistive personnel (UAP) are turning a client
with an abdominal incision, the client's incision eviscerates. Which task is best for the PN to
assign to the UAP?
a. Reposition the client
b. Cover the wound
c. Gather supplies
d. Keep the client calm
Answer: c. Gather supplies
Rationale: Wound evisceration is a protrusion of organs through the incision which can lead to
shock and should be treated as a medical emergency. If this occurs, when a PN and UAP are
working together, it is best for the PN to stay with the client and explain about the urgency of the
situation and instruct the UAP to gather needed supplies and obtain help.
54. The practical nurse (PN) is caring for a client whose urine drug screen is positive for cocaine.
Which behavior should the PN document as evidence of cocaine withdrawal?
a. Elation
b. Intense cravings
c. Hyperactive
d. Talkative
Answer: b. Intense cravings
Rationale: During cocaine withdrawal, the PN should expect the client to experience intense
cravings and a pattern of withdrawal symptoms described as a “crash.”
55. A client with schizophrenia reports auditory hallucinations when admitted to the hospital.
What question is most important for the practical nurse (PN) to include in the assessment of this
client?
a. What are the voices uttering?
b. How does the client cope with the voices?
c. Which medication works best?
d. When are the voices most disturbing?
Answer: a. What are the voices uttering?
Rationale: To ensure the clients safety and the safety of others, it is most important for the PN to
identify the client’s risk for self-injury. If the voices are telling the client to hurt him/herself for
others, immediate interventions is indicated, and the content of command hallucinations should
be assessed.
56. A client who is a gravida 1, para 0, is transferred to the recovery room following a normal
vaginal delivery of a healthy newborn. The practical nurse (PN) observes that the client is
shaking uncontrollably and states she is cold. Which intervention should the PN perform?
a. Take her temperature and assess for additional signs of infection
b. Encourage the client to turn to her left side and administer oxygen by face mask
c. Elevate her legs in a shock position and apply external heat
d. Apply light, warmed blankets and assure her that this is normal following delivery
Answer: d. Apply light, warmed blankets and assure her that this is normal following delivery
57. The practical nurse (PN) is assigned to care for four children. Which child should be assessed
first?
a. 4-year-old who needs to stand to void before going to x-ray
b. 3-year-old who is in isolation with chickenpox lesions and MRSA
c. 2-year-old who is admitted for gastroenteritis and vomiting
d. 18-month-old who has cystic fibrosis and is wheezing
Answer: d. 18-month-old who has cystic fibrosis and is wheezing
Rationale: A young child with cystic fibrosis who is wheezing is demonstrating respiratory
compromise and should be assessed first. The other children be assessed after the child with
respiratory distress.
58. A client with hypertension complains of a persistent dry cough. The practical nurse
(PN)should tell the client that this is a common side effect of which daily medication?
a. Spironolactone
b. Losartan
c. Clonidine
d. Quinapril
Answer: d. Quinapril
Rationale: A persistent dry cough is a side effect if the antihypertensive agent quinapril, an ACE
inhibitor.
59. A female client with immune thrombocytopenic purpura is transferred to a long-term care
facility for physical rehabilitation. To prevent injury, which action is most important for the
practical nurse to implement?
a. Assess the client for nerve pain or paralysis
b. Evaluate client's neurological status after exercising
c. Ensure the client has minimal clutter in the room
d. Monitor the client's blood cell laboratory values
Answer: c. Ensure the client has minimal clutter in the room
Rationale: Immune thrombocytopenic purpura is manifested by low platelet count and increased
capillary fragility, which place the client at risk for bleeding. The priority of care during
rehabilitation is. To ensure the client’s surroundings and pathways are free of obstacles and
clutter that may cause tactile trauma or injury.
60. The practical nurse (PN) determines that a client who is one day postpartum has a moderate
amount of lochia rubra and the uterus is firm, extroverted, and three fingerbreadths above the
umbilicus. Which should be the PN's initial action?
a. Assess the bladder for distension
b. Check the hemoglobin to determine uterine hemorrhage
c. Provide a stool softener for constipation
d. Massage the uterus to decrease atony
Answer: d. Massage the uterus to decrease atony
61. The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and
find the client lying on the bed. The PN determines that the client is unresponsive. Which
instruction should the PN give the UAP first?
a. Bring a glucometer to the room
b. Check the blood pressure
c. Feel for a carotid pulse
d. Obtain emergency help
Answer: c. Feel for a carotid pulse
62. When providing oral care to an unconscious client who is a mouth breather and does not
swallow, which action is most important for the practical nurse (PN) to implement?
a. Use an oral suction catheter in the buccal cavity
b. Inspect the oral cavity using gloved fingers
c. Perform oral cleansing with a sponge tooth Ette
d. Apply a petroleum-based lubricant to the client's lips
Answer: a. Use an oral suction catheter in the buccal cavity
63. A client is scheduled to receive a sublingual tablet and has difficulty swallowing tablets.
Which is the best nursing action?
a. Place the tablet under the client's tongue
b. Crush the medication and administer in applesauce
c. Obtain a liquid form of the medication
d. Place the tablet inside the client's cheek
Answer: a. Place the tablet under the client's tongue
64. 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?
a. Instruct the mother to play with the child for stimulation and distraction
b. Monitor the child's oxygen saturation level via pulse oximeter
c. Encourage the child to drink adequate amounts of cool, clear liquids
d. Administer a dose of acetaminophen per PRN prescription
Answer: a. Instruct the mother to play with the child for stimulation and distraction
65. Which foot care instruction is most important for the practical nurse (PN) to reinforce that
minimizes a long-term complication for a client who is newly diagnosed with type 2diabetes
mellitus (DM)?
a. Report any foot injury or sore that does not readily heal
b. Make sure shoe size fits to minimize rubbing and blisters
c. After washing feet, dry thoroughly between toes
d. Monitor fingerstick glucose daily for tight control
Answer: a. Report any foot injury or sore that does not readily heal
Rationale: The most important information to reinforce is to ensure the client understands to
report poor healing of any tissue damage to the feet which can lead to serious complications,
such as possible amputation.
66. A client is voiding frequent small amounts 24-hours following the removal of an indwelling
catheter, and a post-voided residual volume assessment is prescribed. What explanation should
the practical nurse (PN) provide to the client about why the procedure is necessary?
a. The catheterization is part of the prescribed bladder retraining program
b. The catheterization procedure is an exercise in stimulus response conditioning
c. The catheterized volume determines the need to re-insert the indwelling catheter
d. The catheterization will stimulate the bladder to empty more completely
Answer: c. The catheterized volume determines the need to re-insert the indwelling catheter
Rationale: Use of an indwelling urinary catheter can reduce the muscle tone of the urinary
bladder, resulting in ineffective emptying. The PN should explain that the catheterized volume of
urine indicates how effective the bladder is contracting and if an indwelling catheter needs to be
re-inserted to prevent further retention.
67. An adolescent with a history of recurring atopic dermatitis (eczema) tells the practical nurse
(PN) of a desire to play high school football. Which action should the PN take?
a. Encourage the client to join the swim team instead of the football team
b. Emphasize showering with non-perfumed soaps immediately after practice
c. Discuss with the coach the client's skin condition and manifestations
d. Describe the problems associated with perspiration for those with eczema
Answer: b. Emphasize showering with non-perfumed soaps immediately after practice
Rationale: Heat and humidity can cause perspiration, which intensifies itching with atopic
dermatitis (eczema), so the client should be encouraged to shower, using non-perfumed soaps, as
soon as possible after physical activity to remove perspiration.
68. The practical nurse (PN) is assisting the recreational director of a long-term care facility plan
outdoor activities for the wheelchair-bound older residents who are mentally alert. Which
activity meets the physical and social needs of these residents?
a. An open air concert
b. A tea party in the courtyard
c. A team ring-toss competition
d. A picnic in the park
Answer: c. A team ring-toss competition
Rationale: An outdoor team game of ring-toss provides opportunities for socialization, as well as
exercise. This activity addresses the older clients’ psychosocial, interpersonal, and physical
needs.
69. The parents of a child with acute glomerulonephritis are describing to the practical nurse
(PN) what originally motivated them to seek medical care. Which sign is the child most likely to
have exhibited?
a. Polydipsia
b. Weight loss
c. Hematuria
d. A sore throat
Answer: c. Hematuria
Rationale: Glomerulonephritis is associated with post streptococcal infection and presents with
urine color changes due to hematuria, proteinuria, and renal dysfunction that causes fluid
retention, edema, and hypertension with or without oliguria. The typical motivator for parents to
seek medical help for a child is hematuria.
70. Which food provides the best source of vitamin B12? (Click on the correct location. To
change, click on a new location.)
Answer: Click the meat
Rationale: Animal sources such as meat are high in vitamin B12. Vitamin B12 is not found in
cleaned fruits and vegetables. B12 is a water-soluble vitamin necessary for healthy function of
the brain and nervous system.
71. Which statement by an older female client who lost her spouse 2 years ago should indicate to
the practical nurse (PN) that the client may need bereavement counseling?
a. "I hate that my health does not allow me to do what I used to do."
b. "Sometimes I have trouble remembering simple things."
c. "I realize that life must go on, but sometimes I wonder why."
d. "I depend on children who fortunately live close-by.”
Answer: c. "I realize that life must go on, but sometimes I wonder why."
Rationale: Usually, within 1 year after the death of a spouse, the remaining spouse has accepted
the loss and is adjusted to life without their spouse. Depression and pathological grief based on
the client’s lack of acceptance of life as it is today without the spouse requires bereavement
counseling.
72. Two weeks after cast application, a client with a fractured right arm returns to the clinic for
evaluation. The client seems upset and tells the practical nurse (PN) that the healthcare provider
said a callus has formed on the bone. Which action should the PN take?
a. Report the client's concern to the healthcare provider
b. Prepare to assist in applying a new cast to reduce pressure points
c. Explain that this is an expected part of the bone healing process
d. Teach the client strategies to prevent further calluses
Answer: c. Explain that this is an expected part of the bone healing process
Rationale: Callus formation is visualized on x-ray and is a normal stage of bone repair that
indicates osteoblasts, blood vessels, and fibroblasts are surrounding the fracture site and
initiating cartilage synthesis, bone formation, and healing. The PN should explain this normal
healing process.
73. The practical nurse (PN) is caring for a client with influenza who requires droplet
precautions. Which action should the PN take after entering the client's room to provide care?
a. Apply a fitted N-95 respirator
b. Close the door to the client's room
c. Ask client to apply a face mask
d. Disinfect all flat surfaces in the room
Answer: b. Close the door to the client's room
Rationale: Droplet precautions are intended to prevent transmission of pathogens spread through
close respiratory or mucous membrane contact with respiratory secretions, and include keeping
the door to the client’s room closed.
74. The practical nurse (PN) is obtaining fetal heart rates on four antepartum clients in their third
trimester of pregnancy. Which fetal heart rate should be reported to the registered nurse (RN)
immediately?
a. 152
b. 180
c. 136
d. 118
Answer: b. 180
Rationale: Even though a fetal heart rate of 180 (normal range 110-160) may be an acceleration
secondary to fetal movement, this finding should be reported immediately to the RN because it
indicates tachycardia, which requires further assessment. The other findings are normal fetal
heart rates in the third trimester.
75. The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a bedfast
client was not turned during the night. After turning the client, the UAP noted a reddened area on
the client's hip. The reddened area lightened when light fingertip pressure was applied by the PN.
Which action should the PN take?
a. Instruct the UAP to cleanse the area thoroughly to remove any remaining skin debris
b. Gather supplies to apply a sterile dressing over the site to reduce risk for infection
c. Confirm that turning this client once a shift is sufficient since no skin damage occurred
d. Remind the UAP of the need to turn the client every 2 hours to prevent skin breakdown
Answer: d. Remind the UAP of the need to turn the client every 2 hours to prevent skin
breakdown
76. The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with
decreased air flow in the entire left upper lobe. What should the practical nurse (PN) expect to
hear when auscultating the left upper lobe?
a. A rubbing pleural sound
b. Wheezing
c. Loud crackling sounds
d. Absent or diminished breath sounds
Answer: d. Absent or diminished breath sounds
Rationale: When auscultating the lungs if there is little or no air movement, the breath sounds
are diminished or absent.
77. A client is receiving an epidural anesthesia during labor. Which observation is the most
important adverse effect that the practical nurse (PN) should assess for following the
administration of the epidural?
a. Maternal hypotension
b. Urinary retention
c. A continuous headache
d. A vaginal hematoma
Answer: a. Maternal hypotension
Rationale: Epidural anesthesia can cause peripheral vasodilation. Maternal hypotension is the
most serious adverse effect of epidural anesthesia during labor, which can reduce both maternal
and fetal oxygenation.
78. During morning rounds, a client who is admitted with obsessive- compulsive disorder is in
the dayroom repeatedly washing the top of the same table. Which intervention should the
practical nurse (PN) implement when approaching the client?
a. Provide time for the behavior then guide the client to other activities
b. Assist the client to identify stimuli that precipitates the activity
c. Assist the client to a chair after taking away the cleaning materials
d. Encourage the client to be calm and relax for a little while
Answer: a. Provide time for the behavior then guide the client to other activities
Rationale: Interrupting ritualistic behavior can increase the client’s anxiety. The PN should
allow time for the behavior and then guide the client to activity.
79. A client who is primigravida at term comes to the prenatal clinic and tells the practical nurse
(PN) that she is having contractions every 5 minutes. The PN monitors the client for one hour
using an external fetal monitor and determines that the client's contractions are 7 to 15 minutes
apart, lasting 20 to 30 seconds, with mild intensity by palpation. Which action should the PN
take?
a. Direct the client to check into the hospital within the next hour for evaluation of possible
urinary tract infection
b. Send the client home and tell her to drink at least 1,000 mL of fluid each day to flush her
bladder
c. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes
apart for one hour
d. Tell the client to go directly to the hospital for admission to labor and delivery for active labor
Answer: c. Send the client home and instruct her to call the clinic when her contractions occur 5
minutes apart for one hour
80. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic.
Which immediate intervention should the practical nurse (PN) implement?
a. Suction the oral and nasal passages
b. Turn the infant onto the right side
c. Stimulate the infant to cry
d. Give oxygen by positive pressure
Answer: a. Suction the oral and nasal passages
81. The practical nurse (PN) is assessing an older client with left-sided heart failure (HF).What
intervention is most important for the PN to implement?
a. Measure urinary output
b. Auscultate all lung fields
c. Inspect for sacral edema
d. Check mental acuity
Answer: b. Auscultate all lung fields
82. A male client with tuberculosis returns to the clinic for daily antibiotic injections for a urinary
infection. The client has been taking antitubercular medications for 10 weeks and states he has
ringing in his ears. Which prescribed medication should the practical nurse (PN) report to the
healthcare provider?
a. Isoniazid 300 mg PO daily
b. Rifampin 600 mg PO daily
c. Pyridoxine with a B complex multivitamin
d. Gentamicin 160 mg IM daily
Answer: a. Isoniazid 300 mg PO daily
83. The practical nurse (PN) administers an anticonvulsant that causes photosensitivity. Which
action should the PN take after administering the medication?
a. Monitor the client's temperature hourly x4
b. Remind the client to protect skin from sunlight
c. Provide a snack rich in Vitamins C and D
d. Dim the lights in the client's room for one hour
Answer: b. Remind the client to protect skin from sunlight
Rationale: Medications that cause photosensitivity increase sensitivity to sunlight. The client
should. Be reminded to protect skin from sunlight. The other precautions do not impact
sensitivity to sunlight.
84. A male client with bipolar disorder reports to the practical nurse (PN) that he has not taken
his prescribed medication, divalproex sodium, for the last 6 months. Assessment of which
parameter is most important for the PN to obtain?
a. Hyperactivity
b. Frame of mind
c. Headache pain
d. Speech pattern
Answer: b. Frame of mind
85. The Glasgow Coma Scale is being used to monitor a client who experienced a traumatic
brain injury. What primary assessment should the practical nurse (PN) evaluate?
a. Ability to communicate
b. Cranial nerve status
c. Mental status
d. Level of consciousness
Answer: d. Level of consciousness
Rationale: The purpose of the Glasgow coma scale is to determine the level of consciousness.
Although the status of cranial nerves and the ability to respond verbally is evaluated using this
scale, the primary assessment is to determine the level of consciousness.
86. The practical nurse (PN) is auscultating a client's lung sounds. Which description should the
PN use to document this sound? (Please listen to the audio file to select the option that applies.)
a. Fine crackles
b. Rhonchi → Snoring
c. Wheeze
d. Stridor → Get help
Answer: b. Rhonchi → Snoring
87. While assisting the PN with the admission of a toddler, which intervention should the
practical nurse (PN) implement to make the experience least stressful for the child?
a. Explain all procedures to child and caregiver
b. Remove child's clothing down to the diaper
c. Do a complete head-to-toe exam in sequence
d. Suggest the primary caregiver hold the child
Answer: d. Suggest the primary caregiver hold the child
Rationale: Common fears of a toddler include the loss of parents and fear of strangers. Allowing
the child to be held by the primary caregiver is likely to help reduce the child’s stress.
88. At the beginning of the shift, in which order of priority should the practical nurse (PN)assess
these four clients? (Arrange from highest priority first to lowest priority last.)
Answer: A. An older adult with dizziness whose O2 saturation is 86%.
B. An adult woman with vomiting whose potassium is 2.8 mEq/L.
C. An adult client with an ulcer whose hemoglobin is 9.5 grams/dL.
D. A young adult with a history of asthma whose arterial pH is 7.48.
89. An older male resident of a long-term care facility is awake at 3:30 AM and wandering down
the hall with his pajamas unbuttoned. Which intervention should the practical nurse (PN)
implement?
a. Address the client to determine his needs
b. Direct the client to go back to bed
c. Administer a nighttime sedative
d. Bring the client to sit in the nursing station
Answer: d. Bring the client to sit in the nursing station
90. The practical nurse (PN) and unlicensed assistive personnel (UP) are providing care for a
client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere.
Which action should the PN implement?
a. Carefully observe the interaction between the client and family members
b. Demonstrate to the UAP how to approach the client from the client's left side
c. Instruct the UAP to protect the client's left side when transferring to a chair
d. Ask the UAP to leave the room and assess the client's body for bruising
Answer: c. Instruct the UAP to protect the client's left side when transferring to a chair
Rationale: Neglect syndrome occurs following a stroke when the client loses awareness of the
side of the body affected by the stroke. It is important that caregivers protect the affected side
since the client has lost awareness. Neglect syndrome is not related to abuse or neglect by
caregivers.
91. While turning and positioning a bedfast client, the practical (PN) observes that the client is
dyspneic. Which action should the PN take first?
a. Apply a pulse oximeter
b. Measure blood pressure
c. Notify the charge nurse
d. Observe pressure areas
Answer: a. Apply a pulse oximeter
Rationale: Dyspnea or difficulty breathing can be the result of inadequate oxygenation. When a
client becomes dyspneic, the PN should first apply a pulse oximeter to measure oxygen
saturation level, which guides the need for supplemental oxygen.
92. The practical nurse (PN) is caring for a client receiving a prescription for paroxetine who
suddenly exhibits restlessness, tachycardia, fever, and elevated blood pressure. Which action
should the PN implement first?
a. Withhold the next dose and contact the health care provider
b. Administer a PRN or prescription for benzodiazepine and acetaminophen
c. Obtain a cooling blanket from the hospital central supply department
d. Take the client to a quiet area and provide reassurance
Answer: a. Withhold the next dose and contact the health care provider
93. Which foods should the practical nurse (PN) recommend to a client as good sources of
vitamin K? (Select all that apply.)
a. Eggs
b. Dairy products
c. Bananas
d. Spinach
e. Broccoli
Answer: d. Spinach
e. Broccoli
Rationale: Spinach, broccoli, along with other leafy green vegetables are significant dietary
sources of vitamin K.
94. A client receiving chemotherapy develops a cough that is productive of yellow-tinged
sputum. After determining that the client is febrile, which is the priority action for the practical
nurse (PN) to take?
a. Plan to re-assess the client's temperature in two hours
b. Provide oral hygiene on a regular, frequent schedule
c. Notify the charge nurse of the assessment findings
d. Measure and record the client's intake and output
Answer: c. Notify the charge nurse of the assessment findings
95. Which location should the practical nurse palpate to determine if a client's submandibular
lymph nodes are enlarged?
a. Anterior to the temporal bone
b. Beneath the lower jaw
c. Lateral to the trachea
d. Above the upper jaw
Answer: b. Beneath the lower jaw
Rationale: The submandibular nodes are found beneath the mandible or lower jaw.
96. The practical nurse (PN) is planning evening shift rounds for a group of post operative clients
who all had surgery earlier that day. Which client should the PN check first?
a. A preschooler who had an emergency appendectomy for appendicitis
b. An adolescent with type 1 diabetes (DM) who had an open cholecystectomy
c. An adult with osteomyelitis who had a necrotic bone fragment removed in the foot
d. A post-menopausal client with breast cancer who had a right breast lumpectomy
Answer: a. A preschooler who had an emergency appendectomy for appendicitis
97. Which client information is most important for the practical nurse (PN) to consider when
providing instructions to the unlicensed assistive personnel (UAP) about providing morning care
to a postoperative client?
a. Oriented to person only
b. Blood pressure of 144/84
c. Oxygen saturation measurement of 95 to 96%
d. Urinary output of 50 mL/hour
Answer: a. Oriented to person only
Rationale: A fully oriented person is oriented to person, place, time, and situation (oriented x4).
A person who is only oriented to one of these elements is at risk for injury. The PN should
provide instructions to the UAP about additional support for the client.
98. A married woman comes to the clinic for her annual well-woman physical examination.
During the interview with the practical nurse (PN), the client makes minimal eye contact. The
PN observes yellow bruising to the lower eye and purple bruising on the client's upper arm,
which look like fingerprints. Which question is best for the PN to ask the client?
a. How is your marital relationship?
b. Do you want to see a social worker?
c. Is there something you want to tell me?
d. Is anyone hurting you?
Answer: d. Is anyone hurting you?
Rationale: The PN should ask a direct question that is supportive and non- judgmental, and the
best approach is the question, is someone hurting you
99. The nurse is taking blood pressure of a client admitted with a possible myocardial infarction.
When taking the client’s BP at the brachial artery, the nurse should place the client’s arm in
which position?
Answer: At the level of the heart
100. What are the final parameters that produce blood pressure? (Select all that apply)
a. Heart rate
b. Stroke volume
c. Peripheral resistance
Answer: a. Heart rate
b. Stroke volume
c. Peripheral resistance
101. The PN is preparing to administer a prescription for Cefazolin (Kefzol) 600 mg IMevery six
hours. The available vial is labeled, “Cefazolin (Kefzol) 1 gram,” and the instructions for
reconstitution state, “For IM use, add 2 mL sterile water for injection. Total volume after
reconstitution = 2.5 mL.” When reconstituted, how many milligrams are in each mil of solution?
(Enter numeric value only)
Answer: 1 g = 1000 mg = 1000 mg/mL / 2.5 mL = 400 mL
102. A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one
hour post dilation and D&C, the nurse assesses vital signs and vaginal bleeding. The client
begins to cry softly. How should the nurse intervene?
Answer: Express sorrow for the client’s grief and offer to sit with her
103. The nurse is assessing an older resident of a long-term care facility who has a history of
Benign Prostatic Hypertrophy and identifies that the client’s bladder is distended. The healthcare
provider prescribes post- voided residual catheterization over the next 24 hours and placement of
an indwelling catheter if the residual volume exceeds 100 mL. The client’s PO intake is 600 mL,
and fifteen minutes ago, the client voided 90 mL. What action should the nurse take?
Answer: Catheterize with an indwelling catheter and if the residual volume id greater than 100
mL, inflate the balloon
104. A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the
nurse recognize as Cushingoid side effects?
Answer: Moon face, slow wound healing, muscle wasting sodium and water retention
105. A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for
pain management during the postoperative period following a Lumbar Laminectomy. What
information should the nurse reinforce about the action of this adjuvant pain modality?
Answer: Mild electrical stimulus on the skin surface closes the gates of nerve conduction for
severe pain
106. The nurse explains the 2-week dosage prescription of prednisone (Deltasone) toa client who
has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing
schedule?
Answer: Decrease dosage daily as prescribed
107. The nurse observes that a male client’s urinary catheter (Foley) drainage tubing is secured
with tape to his abdomen and then attached to the bedframe. What action should the nurse
implement?
Answer: Observe the appearance of the urine in the drainage tubing
108. The nurse is with a client when the healthcare provider explains that the biopsy classifies
the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, “What do these
letters T1N0M0, stand for?” Which response should the nurse provide first?
Answer: “The letters stand for tumor size, node involvement, and metastasis
109. A urinary catheter (Foley) with a 5 mL inflated balloon is being removed by the nurse. After
withdrawing 5 mL of fluid from the balloon, the nurse begins to with draw the catheter while the
client is in semi-fowlers position. However, the nurse meets resistance and the client voices
discomfort. What action should the nurse take next?
Answer: Attempt to withdraw additional fluid from the balloon
