HESI Others Practice Test Assessment Version-1 With Answers-100 Solved Questions

Practice Test Assessment Performance
1. The practical nurse (PN) performs a random blood glucose test for a client with a history of
hypoglycemia and complains of dizziness. After test completion, which action should the PN perform
first?
A. Remove gloves and wash hands.
B. Document results and actions in the medical record.
C. Dispose of lancet and test strip in proper receptacle.
D. Discuss the test results with the client.
Answer: C. Dispose of lancet and test strip in proper receptacle.
Rationale:
Disposal of the lancet and test strip (C) prevents the transmission of bloodborne pathogens and is the
priority. (A, B, and D) should follow, implementing sharps precautions.
2. Regarding client confidentiality, what information represents the correct understanding by the practical
nurse of the guidelines set forth by HIPAA (Health Insurance Portability and Accountability Act)?
A. Only clients can pick up their prescriptions at a pharmacy.
B. Past medical records for clients should be stored in a secured place.
C. Computers that access client information cannot be in the public part of a nursing station.
D. Whiteboards with a list of client names are prohibited in areas that the public can see.
Answer: B. Past medical records for clients should be stored in a secured place.
Rationale:
The Health Insurance Portability and Accountability act of 1996 (HIPPA) establishes that records with
protected health information (PHI) must be stored in a secured place. The other options are not part of the
HIPPA act.
3. Which action should the practical nurse (PN) implement to provide a sense of control to a toddler who is
hospitalized?
A. Put a cover over the child's crib.
B. Ask parents to stay with the child.
C. Assign the same nurses to care for the child.
D. Follow the child's usual routines for feeding and bedtime.

Answer: D. Follow the child's usual routines for feeding and bedtime.
Rationale:
Routines are important to toddlers and give the child a sense of control, so following the child's usual
routines during hospitalization should be implemented as much as possible.
4. Which interventions should the practical nurse (PN) implement in the postoperative period for a client
who had surgery for cancer of the oral cavity? (Select all that apply.)
Select all that apply
A. Provide meticulous oral hygiene.
B. Advise the client to avoid straining at stool.
C. Obtain daily weights to determine need for NGT feedings.
D. Observe for temporary or permanent loss of taste.
E. Monitor for gastric indigestion.
Answer: A. Provide meticulous oral hygiene.
C. Obtain daily weights to determine need for NGT feedings.
D. Observe for temporary or permanent loss of taste.
Rationale:
Postoperative problems related to excision of a cancerous lesion in the oval cavity include the risk for
infection, delayed wound healing in the oral mucosa, and gustatory deficits, if the client's tongue is
resected or biopsied. Meticulous oral hygiene reduces oral flora and minimizes the risk for infection.
Monitoring daily weight provides information about the client's need for supplemental NGT feedings to
improve nutritional intake for healing and recovery. Observing for temporary or permanent loss of taste
may indicate trauma of the tongue and glossopharyngeal nerve.
5. Which intervention is most important for the practical nurse to implement when suctioning the
nasopharyngeal airways for a child after cardiac surgery?
A. Perform oropharyngeal suctioning PRN
B. Suction for no longer than 5 seconds at a time.
C. Assess for symptoms of respiratory distress during suctioning.
D. Administer supplemental oxygen before and after suctioning.
Answer: D. Administer supplemental oxygen before and after suctioning.
Rationale:

Hypoxia increases the cardiac workload after cardiac surgery, so supplemental oxygen should be
administered with a manual resuscitation bag before and after suctioning (D) to prevent hypoxia. Although
(A, B, and C) should be implemented, providing oxygenation is most important. To maintain a patent
airway, oropharyngeal suctioning for a child after cardiac surgery should be performed PRN without deep
insertion of the suction catheter which can cause vagal stimulation and laryngospasm. Suctioning should
be intermittent and maintained for no more than five seconds to prevent depleting the oxygen supply.
Signs of respiratory distress warrant cessation of suctioning if the client is experiencing intolerance.
6. A female client with terminal cancer is tearful and is becoming increasingly withdrawn from her family
and the nursing staff. She refuses medications, treatments, food, and frequently says, "Why is God doing
this to me?" Which intervention should the practical nurse implement?
A. Monitor for an increased suicide risk.
B. Implement measures to reduce her pain level.
C. Contact her religious advisor to help her face death.
D. Initiate discussions about her wishes for end-of-life care.
Answer: C. Contact her religious advisor to help her face death.
Rationale:
The client's religious advisor should be contacted to assist the client cope with her spiritual distress
regarding death (C). Although discussions about end-of-life care (D) should be initiated, the client's
religious advisor, family, or healthcare provider should assist her in coordinating her wishes. The client's
physical distress is influenced by (A and B) but do not address her expressed spiritual needs.
7. Which pathophysiological findings are characteristic in children with cystic fibrosis (CF)? (Select all
that apply.)
Select all that apply
A. Diabetes mellitus.
B. Excessive salivation.
C. Abnormal bone ossification.
D. Pancreatic enzyme deficiency.
E. Hypochloremia and hyponatremia.
F. Viscous respiratory secretions.
Answer: D. Pancreatic enzyme deficiency.

E. Hypochloremia and hyponatremia.
F. Viscous respiratory secretions.
Rationale:
Correct selections are (D, E, and F). CF is characterized by exocrine gland dysfunction that produces
thick, tenacious respiratory secretions (F), pancreatic enzyme deficiencies (D), and abnormally elevated
chloride and sodium concentrations in the sweat (E). Diabetes is common with cystic fibrosis but is not a
pathophysiological finding of CF (A). Impaired salivation, not (B), occurs from patchy fibrosis of salivary
glands. Although impaired absorption of vitamin D and calcium utilization can lead to impaired bone
formation (C), it is not considered a hallmark of CF.
8. Which factor should the practical nurse (PN) consider prior to providing morning hygiene care to a male
client who is of Middle-Eastern descent ?
A. Skin color.
B. Economic status.
C. Personal preferences.
D. Sociocultural background.
Answer: C. Personal preferences.
Rationale:
Hygiene is considered an invasion of personal space, and clients vary in their perceptions of how and who
may assist in their care. Personal preferences (C) should be assessed in advance of hygiene care. Skin
color (A), economic status (B), and sociocultural background (D) do not address the client's perceptions or
preferences.
9. The caregiver of an 88-year-old client tells the practical nurse (PN) that the client takes frequent naps
during the day and awakens frequently during the night. Which information should the PN provide?
A. The client should be given a hypnotic to ensure an adequate sleep pattern through the night.
B. To prevent fatigue, an older client should obtain at least 10 hours of sleep in 24 hours.
C. An older client should nap less during the day to ensure a longer sleep pattern at night.
D. It is normal for an aging client to awaken more often during the night and nap during the day.
Answer: D. It is normal for an aging client to awaken more often during the night and nap during the day.
Rationale:

Sleep habits are individualized, but an older client normally sleeps less at night with more naps taken
during the day, so the caregiver should be reassured that this is an expected, normal sleep pattern (D) for
the client. (A) places the client at risk for dependency and is not indicated. (B and C) are inaccurate.
10. The practical nurse (PN) is caring for an older client with an infection. Which finding should the PN
anticipate as a delayed response in this client?
A. Fever.
B. Fatigue.
C. Malaise.
D. Confusion.
Answer: A. Fever.
Rationale:
An early systemic immune response is fever, but older clients are at risk for an impaired immune response
related to chronic illness or polypharmacy, such as anti-inflammatory steroids. This older client may
manifest fever after presenting with fatigue, malaise, and confusion.
11. Which client receiving infusion therapy is the best assignment for the practical nurse (PN)?
A. Client who haemorrhaged and needs a unit of whole blood started on admission to the postoperative
unit.
B. Client who is receiving diltiazem (Cardizem) IV titrated for a heart rate between 60 to 80.
C. Client who requires fingerstick glucose checks while receiving a regular insulin IV solution.
D. Older adult client who is confused and has a peripheral saline lock that should to be flushed every eight
hours.
Answer: D. Older adult client who is confused and has a peripheral saline lock that should to be flushed
every eight hours.
Rationale:
Client acuity is affected by unstable health alterations that require multisystem organ assessment and
determines client care assignments that should be aligned with the PN or RN scope of practice. An older
adult client with a saline lock that is routinely flushed for patency every 8h is a non-complex care
assignment within the scope of practice for the PN.

12. An older client is being discharged from the hospital to return to the assisted living community after
undergoing a right hip replacement. The client is using a four-point walker. When planning the client's
discharge, which member of the healthcare team is most important for the practical nurse to coordinate
continued care for the client?
A. Case manager.
B. Physical therapist.
C. Occupational therapist.
D. Social worker.
Answer: B. Physical therapist.
Rationale:
To establish the client's independence, the physical therapist (B) should continue the client's progression of
mobility in the assisted living facilty. (A, C, and D) are all available ancillary health care members that can
be utilized if needed for other client needs, but (B) is the priority for the client to regain independent
mobility.
13. A new father asks the practical nurse (PN) the reason for placing an ophthalmic ointment in his
newborn's eyes. What information should the PN provide?
A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and
cause visual deficits.
B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's
infected vagina.
C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry
eyes in the newborn.
D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial
ophthalmic infection.
Answer: D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or
chlamydial ophthalmic infection.
Rationale:
Many states mandate prophylactic use of erythromycin ointment in all newborn's eyes within 2 hours of
birth because of the risk of blindness from an ophthalmic infection acquired during a vaginal birth, if the
mother is infected with a gonorrheal or chlamydial organism (D). (A, B, and C) are inaccurate.

14. A client who has been taking furosemide (Lasix) for the past two months is 2 days postoperative for a
suprapubic prostatectomy. After breakfast, the client is in the bathroom straining to have a bowel
movement when he calls the practical nurse (PN) complaining of sudden onset of shortness of breath and
acute chest pain. Which condition should the practical nurse (PN) assess the client?
A. Stable angina pectoris.
B. Pulmonary edema.
C. Pulmonary embolism.
D. Gastroesophageal reflux.
Answer: C. Pulmonary embolism.
Rationale:
The client's postoperative status and possible dehydration related to recent use of Lasix places the client at
risk for pulmonary embolism, which is a postoperative complication characterized by acute chest pain and
shortness of breath precipitated by straining on stool. (A, B, and D) are not characterized by chest pain and
shortness of breath associated with a Valsalva maneuver.
15. Which finding should the practical nurse (PN) report to the healthcare provider that indicates a client
with cirrhosis is progressing to hepatic encephalopathy (hepatic coma)?
A. 2+ pitting edema up to the lower thighs.
B. Serum clotting results three times above normal.
C. Spider nevi (telangiectasias).
D. Serum ammonia levels twice the normal value.
Answer: D. Serum ammonia levels twice the normal value.
Rationale:
Hepatic coma results in cerebral dysfunction when serum ammonia is not eliminated and builds up in the
bloodstream (D). (A, B, and C) are all expected findings for clients with cirrhosis, but elevated serum
ammonia level is indicative of hepatic failure.
16. Which finding in a newborn is most important for the practical nurse (PN) to report?
A. Clinical jaundice evident on the forehead within 24 hours of birth.
B. Icterus color of blanched skin on the thorax at day 3 after birth.
C. Serum bilirubin concentrations less than 2 mg/dl in cord blood.
D. Bilirubin level of 4 mg/dl using a transcutaneous bilirubinometry.

Answer: A. Clinical jaundice evident on the forehead within 24 hours of birth.
Rationale:
Jaundice is clinically visible when bilirubin levels reach 5 to 7 mg/dl and appears in a cephalocaudal
manner, first noticed in the head and then progresses gradually to the thorax, abdomen, and extremities.
Clinical jaundice that is evident within 24 hours of birth (A) warrants immediate attention and is
pathological. Although additional assessments of physiological jaundice (B) should be made, jaundice in
the first 24 hours is life threatening and requires immediate intervention. Neonatal serum bilirubin levels
(C) (range is 1 to 12 mg/dl in the first week of life) and transcutaneous bilirubin meters (D) provide
accurate measurements for planning care, but jaundice in the first 24 hours, despite serum bilirubin levels,
is the priority.
17. The practical nurse (PN) is reviewing the medical record for an infant with hydrocephalus. Which
focused assessment finding should the PN document?
A. Constricted pupils.
B. A sunken anterior fontanel.
C. Increased head circumference.
D. Decreased luminosity of the head.
Answer: C. Increased head circumference.
Rationale:
A classic sign of hydrocephalus is an increase in head circumference (C) due to the increase in
cerebrospinal fluid (CSF), which should be identified during a focused assessment and documented in the
medical record. The pupils are not constricted (A) with hydrocephalus. A sunken anterior fontanel (B)
occurs with dehydration. Due to the increase in CSF, there is an increase in luminosity of the cranium, not
(D).
18. Which incident should the practical nurse identify as a client confidentiality violation under the Health
Insurance Portability Accountability Act (HIPAA) regulations?
A. A nurse conveys client status information to an inquiring friend on the phone without the client's
permission.
B. The unit secretary faxes a client's old records from the office to the emergency center without a written
consent.
C. A client overhears a verbal prescription in the next room during a cardiac arrest of another client.

D. A client discusses his personal history of kidney stones with another client in the unit's lounge area.
Answer: A. A nurse conveys client status information to an inquiring friend on the phone without the
client's permission.
Rationale:
HIPAA requires that client permission should be obtained before releasing any client information to
unknown parties or non-caretaking individuals. The other options are not HIPPA violation.
19. The practical nurse (PN) is planning care for a client who is admitted with a Braden scale score of 2 in
each of the six subcategories. Toward which goal in the client's care should the PN focus nursing
interventions?
A. Prevention of pressure ulcers.
B. Improved hygienic measures.
C. Temperature within normal limits.
D. Absence of signs of infection.
Answer: A. Prevention of pressure ulcers.
Rationale:
The Braden scale measures degrees of sensory perception, moisture, activity, mobility, nutrition, friction,
and shear that indicate a client's risk for skin breakdown. A score of 12 indicates the client's plan of care
should include a goal that focuses on the prevention of skin breakdown (A). Improved hygiene (B), normal
temperature (D), and absence of infection (C) are related to altered skin integrity, but this assessment tool
allows the nurse to plan interventions to prevent skin breakdown.
20. The practical nurse (PN) is caring for a child who is receiving chemotherapy for leukemia. The child's
granulocyte count is 250/ mm3 and the platelet count is 20,000/ mm3 Which intervention should the PN
implement when performing oral hygiene?
A. Use a toothbrush and floss once a day.
B. Rinse the mouth out with lukewarm water.
C. Clean the teeth with a toothbrush twice daily.
D. Wipe teeth with moistened gauze sponges.
Answer: D. Wipe teeth with moistened gauze sponges.
Rationale:

Based on the child's laboratory results, the child is at risk for bleeding and infection. To minimize trauma
and the risk of bleeding, the PN should cleanse the teeth with moistened gauze sponges (D). (A and C)
create friction and can cause the gums to bleed. (B) provides minimal removal of plaque build-up.
21. An older Hispanic male is admitted with a nutritional deficiency and is prescribed a regular diet. The
client frequently says that he dislikes the hospital foods and wants to eat food brought in by his family.
Which response is best for the practical nurse (PN) to provide?
A. Thank the family for bringing the foods that the client likes to eat.
B. Request that the dietitian review the nutritional content of family foods.
C. Warn the family about the need for adequate food temperature control.
D. Explain to the family that the hospital is providing a balanced diet.
Answer: B. Request that the dietitian review the nutritional content of family foods.
Rationale:
Culture affects acceptability of food, as well as patterns of food intake. Since nutritional requirements
depend on many factors, adequacy of the diet brought by the family should be determined (B). Although
(A, C, and D) may be implemented, the client's preferences should be considered to ensure the client eats a
diet that meets his nutritional needs.
22. Which anticholinergic agent is used for bradydysrhythmias?
A. Atropine.
B. Hyoscyamine (Levsin).
C. Dicyclomine (Bentyl).
D. Glycopyrrolate (Robinul).
Answer: A. Atropine.
Rationale:
Atropine (A) is an anticholinergic drug that increases the heart rate and is used in bradydysrhythmias. (B)
is used to manage gastric secretion and spastic bladder spasm. (C) is used to treat disturbances of GI
motility, such as irritable bowel syndrome. (D) is used as an antisecretory.
23. Which question should the PN ask an older male client to best determine the nature of his pain?
A. "How bad is it?"
B. "Can you describe the pain for me?"

C. "Did the pain medication give you relief?"
D. "Is this pain the same as you had before?"
Answer: B. "Can you describe the pain for me?"
Rationale:
Having the client describe the pain in his own words (B) determines the nature and severity of the present
sensations. (A) is a close-ended question and does not help the client focus on the specific character of the
pain. (C) is an evaluation of therapy. (D) does not describe the current experience of pain.
24. A young child is brought to the emergent care center whose mother is screaming hysterically and states
that her child has been beaten. The practical nurse (PN) finds the unlicensed assistive personnel (UAP)
crying in the hallway about the child's condition. What action should the PN take?
A. Remind the UAP to control her feelings while at work.
B. Call for the chaplain to come and speak to the UAP.
C. Support the UAP by going to a private area to talk.
D. Walk past the UAP in order to allow for privacy.
Answer: C. Support the UAP by going to a private area to talk.
Rationale:
The PN should offer emotional support by going with the UAP to a private area to talk about the situation
(C). (A and D) ignore the emotional impact the client's case has made on the staff member. (B) may be
indicated if the staff member requests additional support.
25. An infant is admitted to the hospital with dehydration and diarrhea. What is the best liquid that the
practical nurse (PN) should provide?
A. Pedialyte.
B. Water.
C. Apple juice.
D. Ginger ale.
Answer: A. Pedialyte.
Rationale:
Infants with acute diarrhea and dehydration should be offered oral rehydration solutions (ORS) that do not
contribute to diarrhea. Pedialyte (A) is a commercially prepared over-the counter ORS that provides the
infant with fluids and electrolytes. Fluids with a high glucose or sodium content, such as fruit juice (C),

colas, and soft drinks (D), should not be used. After an infant is rehydrated with an ORS, maintenance
fluid therapy can progress with alternating an ORS with a low-sodium fluid, such as water (B), and simple
protein and starch feedings, such as rice, potato, yogurt, fruits, vegetables, cereal, or bread, which can
lessen fluid loss.
26. The practical nurse (PN) is caring for a school-aged child with Reye's syndrome. What action is most
important for the PN to implement?
A. Observe the skin for petechiae.
B. Reposition every 2 hours.
C. Monitor intake and output.
D. Perform range-of-motion exercises.
Answer: C. Monitor intake and output.
Rationale:
Reye's syndrome is characterized by a nonspecific encephalopathy with fatty degeneration of the liver and
is triggered by a virus, particularly influenza or varicella, in association with the concurrent use of
salicylates. Fluid management focused on monitoring and treating increased intracranial pressure (ICP) is
crucial, so monitoring intake and output (C) is essential for adjusting fluid volumes to prevent both
dehydration and cerebral edema. Although (A, B, and D) should be implemented, (C) is essential in
preventing life-threatening complications related to ICP.
27. The practical nurse (PN) is caring for a 2-year-old child with Wilms' tumour. Which intervention is
most important for the PN to implement?
A. Check skin turgor for elasticity and hydration.
B. Place a sign in the room stating no abdominal palpation.
C. Auscultate all lung fields for abnormal breath sounds.
D. Distract the child with a toy during daily assessments.
Answer: B. Place a sign in the room stating no abdominal palpation.
Rationale:
Abdominal palpation in a child with Wilms' tumour can cause the cancer to spread throughout the
peritoneum, so it should be prohibited by placing a sign in the child's room.
28. Based on these clients' laboratory results, which client should be assigned to the practical nurse (PN)?

A. Client with a serum sodium of 129 mEq/L.
B. Client with a serum calcium of 9.5 mg/dl.
C. Client with a serum potassium of 6.0 mEq/L.
D. Client with a serum phosphorus of 2.7 mEq/L.
Answer: B. Client with a serum calcium of 9.5 mg/dl.
Rationale:
Non-complex client acuity determines client care assignments that should be aligned with the PN's scope
of practice. Client who has a serum calcium (9.5 mg/dl) within normal limits is least likely to experience
complications and is the best assignment for the PN.
29. A terminally ill male client and his family are requesting hospice care after discharge and ask the
practical nurse (PN) to explain what kind of care they should expect. The PN should indicate that hospice
philosophy focuses on what aspect of health care?
A. Offers ways to postpone the death experience at home.
B. Facilitates assisted suicide with the client's consent.
C. Provides training for family members to care for the client.
D. Enhances symptom management to improve end-of-life quality.
Answer: D. Enhances symptom management to improve end-of-life quality.
Rationale:
Symptom management (D), such as pain control and comfort measures, is part of the philosophy of
hospice care. Hospice philosophy does not include ways to postpone death (A), support for assisted suicide
(B), or ensure family members are capable caregivers (C).
30. Which action should the practical nurse (PN) implement when giving medications to a 3-year-old
child?
A. Instruct the child of the urgency to take the medication right away.
B. Offer the child the option to take the medication orally or by injection.
C. Compare the child's actions to another child who readily takes medication.
D. Allow the child to choose fruit punch or apple juice with oral medications.
Answer: D. Allow the child to choose fruit punch or apple juice with oral medications.
Rationale:

Giving the child the chance to make a choice between fruit punch or apple juice allows the child to exert
control when medications are required during hospitalization and therefore obtain the child's cooperation.
31. Based on The Joint Commission (TJC) standards for pain assessment and treatment, which action is
most important for the practical nurse (PN) to implement when assessing a client?
A. Use a pain scale to assess all clients for pain when obtaining vital signs.
B. Collect objective information about pain to provide the best prescribed treatment.
C. Prioritize pain assessment for surgical clients before clients with chronic illness.
D. Give prescribed medications to all clients with outward expressions of pain.
Answer: A. Use a pain scale to assess all clients for pain when obtaining vital signs.
Rationale:
The priority action, consistent with TJC pain standards, includes assessing all clients for pain, the fifth
vital sign, which is best determined with a pain scale (A). Although objective data (B) are valuable in
using prescriptions for a client in pain, all clients, including those with no pain, should be assessed. A
client with acute pain in the early postoperative phase does not necessitate prioritized assessment (C) over
other clients with chronic pain or endof-life distress. A client's outward expressions of pain should be
validated with a client's own subjective assessment of pain intensity and duration and the need for
analgesic (D).
32. A client with deep partial-thickness and full-thickness burns of the face and chest is receiving wound
care using the "open method." The plan of care includes the nursing diagnosis, "Risk for infection related
to impaired tissue integrity." Based on the expected outcome, "Client remains free of infections," which
nursing intervention should the practical nurse (PN) implement?
A. Wear gown, cap, mask, and gloves during direct client care.
B. Restrict visitors in order to prevent wound contamination.
C. Use sterile water for debridement in the hydrotherapy tank.
D. Apply sterile dressings after debridement of burn wounds.
Answer: A. Wear gown, cap, mask, and gloves during direct client care.
Rationale:
The burn area is exposed and an aseptic environment is needed to prevent contamination and infection.
Protective isolation precautions should be implemented during direct client care and wound care which
should include wearing gown, cap, mask, and gloves. The other options are not required.

33. The practical nurse provides information to a client about collecting a 24-hour urine specimen. Which
statement indicates the client needs additional information?
A. "I should continue to take my prescribed heart medicines."
B. "At the beginning of the test, I should add the preservative to the container."
C. "I should begin the collection with the first voided specimen when I get up in the morning."
D. "At the end of the 24 hours, I should urinate and add this last specimen to the container."
Answer: C. "I should begin the collection with the first voided specimen when I get up in the morning."
Rationale:
The 24-hour urine collection specimen starts when the client first arises, discarding the first voided
specimen, and notes the start time of urine collection.
34. During a prenatal visit, expectant parents ask the practical nurse (PN) how to safely transport a
newborn home in a car seat. What information should the PN provide?
A. The car seat should be secured in the front seat using the seatbelt.
B. The chest harness should slide over the newborn's abdomen.
C. A car seat should be in the rear facing position in the back seat.
D. An infant should be elevated at a 60 degree angle while in the car seat.
Answer: C. A car seat should be in the rear facing position in the back seat.
Rationale:
Infants should travel only in federally approved, rear-facing safety seats secured in the rear seat from birth
to 20 pounds and to 1 year of age. The other options are inaccurate.
35. Which client should the practical nurse (PN) identify as the priority for a focused assessment?
A. Older female with pneumonia who is newly confused to person.
B. Adult male who is receiving an IV infusion reports his arm is cold.
C. Older male with serum potassium of 3.2 mEq/L on first postoperative day.
D. Adult female with white cell count of 9,900 mm3 who has pyelonephritis.
Answer: A. Older female with pneumonia who is newly confused to person.
Rationale:

A new onset of change in a client's mental status (A) is often related to poor perfusion and cerebral
oxygenation and should be assessed first. (B and C) should be assessed next. (D) is an expected finding
with infection.
36. The practical nurse (PN) is administering a dissolved medication via a nasogastric tube (NGT). After
putting on gloves and attaching the irrigation syringe to the NGT, in which order should the PN implement
the actions? ( Arrange from first on top to last on the bottom.)
A. Pinch the tubing to pour 15 to 30 ml of tap water in the syringe barrel.
B. Release the tubing slowly to allow the solution to flow.
C. Observe the client for indications of intolerance during instillation.
D. Add the medication solution after pinching the tubing.
Answer: A. Pinch the tubing to pour 15 to 30 ml of tap water in the syringe barrel.
B. Release the tubing slowly to allow the solution to flow.
C. Observe the client for indications of intolerance during instillation.
D. Add the medication solution after pinching the tubing.
Rationale:
The next step is to pinch the tubing as tap water is added to the syringe barrel to flush the NGT and ensure
its patency. The tubing should be released slowly to allow the solution to flow by gravity instillation.
During the instillation of any solution, such as flushed water, liquid medication, or formula, into an NGT,
the client should be observed for signs of intolerance. The tubing should be pinched to prevent air from
entering the stomach and to control the flow of the medication as it is added.
37. Which nursing action for a client who was bitten by a black widow spider is within the scope of
practice of the practical nurse (PN)?
A. Provide discharge wound care instructions.
B. Assess for respiratory compromise.
C. Administer intramuscular (IM) tetanus toxoid.
D. Determine degree of tissue destruction.
Answer: C. Administer intramuscular (IM) tetanus toxoid.
Rationale:
The administration of IM injections is within the scope of practice for the PN . Although the PN gathers
data, assessment , discharge planning, and instruction are the responsibility of the registered nurse (RN).

38. What action should the practical nurse (PN) take when implementing daily focused assessments for
this assigned group of 4 clients?
A. Apply a blood pressure cuff on client's forearm when the upper arm cannot be used.
B. Measure a child's length from feet to shoulders using a Brose low tape.
C. Palpate the abdomen prior to auscultation for presence of bowel sounds.
D. Dispose of the gastric residual volume after aspirating the client's nasogastric tube.
Answer: A. Apply a blood pressure cuff on client's forearm when the upper arm cannot be used.
Rationale:
Blood pressure cuff placement on the forearm and calf can be used to obtain an accurate reading when a
cuff cannot be placed on the upper arm.
39. Which client information determines the best assignment for the practical nurse (PN)?
A. Client who takes spironolactone has a serum potassium of 5.9 mEq/L.
B. Client with dependent edema is scheduled for discharge to home care.
C. Client who is admitted in the morning is having severe vomiting and diarrhoea.
D. Client with a non-tunnelled central catheter has severe fluid volume deficiency.
Answer: B. Client with dependent edema is scheduled for discharge to home care.
Rationale:
Non-complex client acuity determines client care assignments that should be aligned with the PN's scope
of practice. The PN should be assigned to a stable client with residual dependent edema who is preparing
for discharge. Clients with complex diagnosis and higher acuity would require the expert skills of the RN.
40. What action should the practical nurse implement to facilitate speech for a client who has a fenestrated
tracheostomy tube?
A. Show the client how to use a tracheostomy plug.
B. Determine the client's ability to swallow.
C. Remove the inner cannula.
D. Give oxygen at 6 L/minute via tracheostomy collar.
Answer: B. Determine the client's ability to swallow.
Rationale:

A fenestrated tracheostomy tube has an opening or hole on the posterior aspect of the outer cannula that
allows airflow over the vocal cords and speech in a client who is spontaneously breathing. A fenestrated
tube does not have a cuff, so the client's risk for aspiration should be determined.
41. Rank the sequence of physiological changes that a newborn must initiate and adapt to extrauterine life
after Cesarean delivery? (Arrange in the order from most critical on top to least on the bottom.)
A. Initiation of respirations.
B. Maintenance of body temperature.
C. Closure of fetal circulatory shunts.
D. Response of immune defense system.
Answer: A. Initiation of respirations.
B. Maintenance of body temperature.
C. Closure of fetal circulatory shunts.
D. Response of immune defense system.
Rationale:
The most critical physiological adaptation of a newborn at birth is the establishment of respirations.
Following the establishment of respirations, heat regulation is critical to newborn survival. The
cardiovascular system changes after birth are the result of fetal respiration that reduces pulmonary vascular
resistance to the pulmonary blood flow and initiates fetal circulatory changes. The infant relies on passive
immunity received from the mother for the first 3 months of life, which is followed by the infant's
immunological responses to microbial exposure.
42. Which finding should the practical nurse report that is the first indication a child with a tracheostomy
is experiencing respiratory distress?
A. Cyanosis.
B. Restlessness.
C. Sternal retractions.
D. Crowing respirations.
Answer: B. Restlessness.
Rationale:
Unless respiratory arrest occurs suddenly, signs of hypoxemia and hypercapnia are usually subtle and
become more obvious as respiratory distress progresses. A child with a tracheostomy may develop airway

obstruction from increased airway secretions, which decreases cerebral oxygenation, initially causing
restlessness (B), and should be reported immediately. (A, C, and D) are clinical manifestations of severe
hypoxia.
43. The practical nurse (PN) is reviewing the use of a new digital thermometer with a group of unlicensed
assistive personnel (UAP). Which indicator should the PN use to best evaluate that the UAPs understand
the use of the thermometer?
A. UAPs who score 100% on a written test are competent.
B. UAPs have no questions and indicate understanding.
C. Randomly-chosen UAPs state step-by-step directions.
D. UAPs are repeatedly observed using equipment correctly.
Answer: D. UAPs are repeatedly observed using equipment correctly.
Rationale:
The best evaluation of a skill, such as use of a digital thermometer, is correct performance of the skill
during return demonstration (D). (A and C) indicate cognitive learning, but (D) is the best indicator of safe
practice. (B) does not ensure the skill can be performed correctly.
44. A female client who is newly diagnosed with Type 2 diabetes tells the practical nurse (PN) that she
hates to exercise and asks whether just following her 1000-calorie diet will control her diabetes. Which
response should the PN provide that offers the best information?
A. To ensure an increased energy and a sense of well-being, diet and exercise should be balanced.
B. Exercise facilitates weight loss and decreases peripheral insulin resistance.
C. To improve cardiovascular and respiratory fitness, a regular routine for exercise should be practiced.
D. A routine pattern for meal scheduling is needed for tight glucose control.
Answer: B. Exercise facilitates weight loss and decreases peripheral insulin resistance.
Rationale:
Exercise increases insulin sensitivity and has a direct effect on lowering the blood glucose levels. Dietary
compliance and regular exercise contribute to weight loss, which also decreases insulin resistance (B).
While (A, C, and D) are accurate, (B) provides the best information for client compliance.
45. Which information related to a client's history of benign prostatic hypertrophy (BPH) should the
practical nurse (PN) report to the healthcare provider?

A. Change in bowel movements.
B. Persistent lower back pain.
C. White penile discharge.
D. Difficulty with urination.
Answer: D. Difficulty with urination.
Rationale:
An increase in the size of the prostate gland caused by BPH compresses the urethra, resulting in difficulty
initiating the urinary stream. This should be reported to the healthcare provider.
46. The practical nurse (PN) is reviewing the medication dosage instructions with a parent whose child is
taking levothyroxine (Synthroid). What statement reveals that the parent understands the correct
procedure?
A. "I don't give the medication on the weekends."
B. "I give the medication at 8:00 am every day."
C. "I am using a different brand now because it costs less money."
D. "I stopped giving the medication because my daughter was losing her hair."
Answer: B. "I give the medication at 8:00 am every day."
Rationale:
A child with hypothyroidism should receive Synthroid every day at the same time therefore, stating that
she gives the medication at 8:00am everyday indicates correct understanding. The other options indicate
the need to teaching.
47. A male client diagnosed with schizophrenia reveals to the practical nurse (PN) that voices have told
him he is in danger. He believes he is safe only if he stays in his room and wears the same clothes. He goes
on, "They're so loud they frighten me. Don't you hear them?" What is the best response for the PN to
provide?
A. "I know these voices are very real to you, but I don't hear them."
B. "Tell me more about the voices and if they are men or women."
C. "You're safe in the hospital and nothing will happen to you."
D. "You should get out of your room so you don't hear the voices."
Answer: A. "I know these voices are very real to you, but I don't hear them."
Rationale:

When asked to validate the hallucination, the PN should respond with the reality that the nurse is not
experiencing the same stimuli as the client (A). Although asking the client about the content of a
hallucination provides information about directions for self-harm, (B) is not relevant. (C) negates the
client's feelings and his reality of the hallucination. (D) is non-therapeutic and ineffective.
48. A client with a common cold is seeking treatment at the health clinic. What information should the
practical nurse (PN) reinforce to reduce the spread of infection to family members?
A. Wash hands after each use of a tissue for nasal drainage.
B. Use a dishwasher for all personal dishes and utensils.
C. Recommend wearing a mask until all cold symptoms subside.
D. Sleep alone in a room and use a humidifier.
Answer: A. Wash hands after each use of a tissue for nasal drainage.
Rationale:
Handwashing after sneezing, coughing, and blowing the nose is the best defense in reducing the risk of
spreading viruses directly or indirectly to others. The other options are not effective in minimizing
airborne spread or direct contact with viruses found in the client's nasal and bronchial secretions.
49. An older client is admitted with anaemia after an episode of acute blood loss. Which assessment
finding should the practical nurse (PN) report?
A. Refuses green, leafy vegetables.
B. Output 150 ml dark amber urine.
C. Red and tender joints in hands.
D. Tarry stool last bowel movement.
Answer: D. Tarry stool last bowel movement.
Rationale:
Anaemia due to an acute episode of blood loss, such as gastrointestinal bleeding, can cause tarry stools (D)
and should be reported. Although a deficiency of iron, vitamin B12, folic acid, intrinsic factor, or a
decrease in red blood cells (RBC) production or an increased destruction of RBCs cause other anemias,
acute blood loss is unrelated to (A and C).Concentrated urinary output may indicate dehydration, not
anemia (B).

50. What action should the practical nurse (PN) implement when administering ear drops to a 2-year-old
child?
A. Insert a sterile cotton ball into the ear canal.
B. Pull the pinna back and down to instill the drops.
C. Massage the helix after medication administration.
D. Give the ear drops upon removal from the refrigerator.
Answer: B. Pull the pinna back and down to instill the drops.
Rationale:
When instilling ear drops to a child under 3 years of age, the ear canal is straightened by pulling the pinna
back and down (B). A cotton ball can be placed at the entrance of the ear canal, but a sterile cotton ball is
not necessary (A). The targus, not the helix (C) or upper portion of the ear, can be massaged to ensure the
medication reaches the tympanic membrane. Instilling cold ear drops (D) causes pain, and drops should be
warmed to room temperature prior to administration.
51. A client is wearing a continuous 24-hour Holter monitor for evaluation of heart rhythm disturbances.
What information should the practical nurse (PN) reinforce with this client?
A. Remove the electrodes to shower or bathe.
B. Keep a diary of activities as long as the monitor is worn.
C. Exercise as much as possible while the monitor is in place.
D. Call the assigned number if an episode of irregular heartbeats occurs.
Answer: B. Keep a diary of activities as long as the monitor is worn.
Rationale:
Nursing care for a client with a Holter monitor includes preparation of the skin, placement of the
electrodes and leads, and activities of daily living, so the client should be informed of the importance of
keeping an accurate record of activities and symptoms.
52. Which statement by the mother of a newborn should alert the practical nurse (PN) to offer further
information about the care of the umbilical cord?
A. "I will use warm water to wash my baby's diaper area with each change."
B. I am going to sponge bathe my baby for the first couple of weeks."
C. "I can't wait to bathe my baby in the new baby tub as soon as I get home."
D. "I should keep the cord area dry and use an alcohol wipe until the cord falls off."

Answer: C. "I can't wait to bathe my baby in the new baby tub as soon as I get home."
Rationale:
The infant should not be submerged in a tub bath until the umbilical cord dries and falls off. The mother's
eagerness (C) should be addressed to determine the need to reinforce home care of the newborn's cord.
Plain water (A) for diaper care, sponge baths (B), and cord care with an alcohol wipe until the cord falls
off in 10 to 14 days (D) are statements indicating the mother understands infant care.
53. The practical nurse (PN) is assessing a client who is admitted with a history of heart failure (HF) and a
recent onset of dependent edema. Which finding is most important for the PN to report?
A. Weight loss.
B. Weak, thready pulse.
C. Crackles in the lungs.
D. Decreased blood pressure.
Answer: C. Crackles in the lungs.
Rationale:
A client with a history of HF is at risk for cardiac decompensation, so signs of fluid overload, such as
dependent edema and crackles in the lungs (C), should be reported. (A and D) are expected outcomes of
effective management of heart failure and are not typical of decompensation, which requires immediate
attention. Although (B) should be reported, the accumulation of pulmonary fluid compromises the client's
tissue oxygenation and is most significant.
54. The practical nurse (PN) is observing a newborn’s breathing pattern. Which breathing pattern should
the PN document as normal for this full-term newborn?
A. Deep breaths with a normal regular rhythm.
B. Thoracic breathing with nasal labial flaring.
C. Diaphragmatic breathing with chest retraction.
D. Synchronal chest and abdominal movements.
Answer: D. Synchronal chest and abdominal movements.
Rationale:
Abdominal movements synchronous with chest movements (D) are normal in a healthy full-term infant.
Chest breathing is not the typical pattern, whereas nasal flaring (B) and chest retractions (C) are signs of

respiratory distress (B). A normal breathing pattern in a neonate is shallow and irregular in rate, rhythm,
and depth, not (A).
55. The practical nurse (PN) is planning to attend an educational offering for continuing education units
(CEUs) or contact hours. In order to qualify for CEUs, the PN must recognize that the offering should
include which essential element?
A. Has at least one speaker with a master's degree.
B. Demonstrate a need by assessment survey.
C. Has measurable outcome objectives.
D. Includes a question and answer period at the end.
Answer: C. Has measurable outcome objectives.
Rationale:
Most state boards of nursing provide rules and regulations about required continuing education units
(CEU) or credits for renewal of licensure for continued nursing practice and describe that a CEU offerings
must identify measurable outcome objectives (C). (A, B, and D) are not required in the CEU offering.
56. The practical nurse (PN) receives an assignment of four clients. Which action should the PN
implement first?
A. Administer the morning dose of aspirin 81 mg to a client with a history of angina.
B. Take the blood pressures on both arms of a client with moving, "ripping" back pain.
C. Notify the healthcare provider that a client with a L3 fracture cannot move either leg.
D. Obtain further information from a client with multiple sclerosis who reports ataxia and diplopia.
Answer: B. Take the blood pressures on both arms of a client with moving, "ripping" back pain.
Rationale:
Moving, "ripping" back pain may be a symptom of an aortic aneurysm dissection, which creates changes
in the blood flow volume between the right and left subclavian arteries. The PN should determine if the
client has a difference in arterial blood pressures in both arms (B) and report these findings to the charge
nurse. (A, C, and D) are a lower priority than (B).
57. A client is 24 hours post-endoscopic retrograde cholangiopancreatography (ERCP) for cholelithiasis.
Which finding should the practical nurse (PN) report to the healthcare provider?
A. Serum bilirubin elevation four times above normal value.

B. Serum amylase elevation 3 times above normal value.
C. Steatorrhea.
D. Jaundiced sclera.
Answer: B. Serum amylase elevation 3 times above normal value.
Rationale:
ERCP can cause a gallstone to move into the common bile duct, obstructing flow into the duodenum and
cause pancreatitis, which is evidenced by an elevation of serum amylase and lipase levels.
58. The practical nurse (PN) is working in the eye clinic where several clients are waiting to be seen.
Which client should the PN place in the ophthalmologist's examination room first?
A. An adolescent with photosensitivity due to something in the right eye.
B. An older client with unilateral blurry vision over the past year.
C. An adult male with a sudden onset of a curtain across field of vision today.
D. A female client with erythremic eyelids and scales on eyelashes.
Answer: C. An adult male with a sudden onset of a curtain across field of vision today.
Rationale:
A sudden onset of loss of vision as if a curtain fell across the visual field is a classic symptom of retinal
detachment (C) that requires emergency treatment. (C) takes priority over a possible foreign body in the
eye (A), possible cataract (B), and blepharitis (D).
59. The practical nurse (PN) is providing wound care for a newly admitted client with partial to fullthickness burns of the torso. Place the steps in the order of first to last implementation.
(Arrange from first on top to last on the bottom.)
A. Maintain room temperature above 76 F.
B. Administer prescribed opioid analgesic.
C. Don gown, mask, and gloves.
D. Cleanse wounds with sterile normal saline.
E. Apply topical silver sulfadiazine (Silvadene).
Answer: C. Don gown, mask, and gloves.
D. Cleanse wounds with sterile normal saline.
A. Maintain room temperature above 76 F.
E. Apply topical silver sulfadiazine (Silvadene).

B. Administer prescribed opioid analgesic.
Rationale:
The dressing change procedure should proceed in the order of (C, D, A, E, and B). Skin functions as the
first barrier to microorganism invasion and body heat regulation. Before preparing for the dressing change
of partial to full-thickness burns, the room temperature should be above 76 F to reduce heat loss from the
burned area. Next the client should be medicated with an opioid analgesic to reduce pain during the
dressing change. To reduce the risk of wound contamination, protective attire (gown and mask) should be
donned and sterile gloves used during the procedure. Sterile normal saline is used to cleanse and remove
tissue debris before application of a topical anti-infectant, such as silver sulfadiazine.
60. The practical nurse (PN) is talking with an adult male client who says that he is satisfied with how he
has lived his life. According to Erikson's staging theory, this client is in which stage?
A. Integrity versus despair.
B. Intimacy versus isolation.
C. Identity versus role confusion.
D. Generativity versus stagnation.
Answer: A. Integrity versus despair.
Rationale:
According to Erikson's Ego theory and developmental model, an older adult who reviews one's life
experiences with a sense of satisfaction and is at peace with inevitable death is in the stage of integrity
versus despair. The other choices are not in this stage.
61. Which client requires the most immediate assessment by the practical nurse?
A. An adolescent with a head laceration oozing serosanguinous drainage.
B. A young adult post-appendectomy with an increase in wound drainage.
C. A middle-age male with a recent urostomy showing pale yellow drainage.
D. An elderly client with a dry dressing over a diabetic ulceration on the great toe.
Answer: B. A young adult post-appendectomy with an increase in wound drainage.
Rationale:
A client who is post-appendectomy with a sudden increase in wound drainage (B) should be assessed
immediately for potential wound dehiscence. The client with a head laceration (A) and the client with a

recent urostomy (C) are demonstrating expected findings. The client with a diabetes ulceration (D) does
not need immediate attention as does (A).
62. A client with advanced cirrhosis is prescribed lactulose (Cephulac) 30 ml QID. The client complains
that the medicine is causing diarrhoea. Which therapeutic response of the medication should the PN
provide the client?
A. Promotes fluid loss.
B. Prevents constipation.
C. Excretes ammonia to improve cerebral function.
D. Reduces the risk for gastrointestinal bleeding.
Answer: C. Excretes ammonia to improve cerebral function.
Rationale:
Lactulose causes the movement of serum ammonia, which accumulates due to hepatic dysfunction in
cirrhosis, into the gut resulting in diarrhoea due to the osmotic movement of water. The primary use in
advanced cirrhosis is to reduce serum ammonia levels. The other options are not therapeutic actions for
lactulose.
63. The nursing staff team includes a registered nurse (RN), a practical nurse (PN), and an unlicensed
assistive personnel (UAP). Which task should be assigned to the PN?
A. Stocking the linen closet with additional sheets.
B. Assigning lunch times for each team member.
C. Changing decubiti dressings for an immobile client.
D. Administering blood to a client with active GI bleeding.
Answer: C. Changing decubiti dressings for an immobile client.
Rationale:
The PN is skilled in caring for a client who is stable and needs dressing changes. The UAP should be
assigned unskilled tasks, while the RN can perform tasks that require complex care and frequent
assessment.
64. The practical nurse (PN) receives report for four clients. While providing care, which client should the
PN observe closely for hypernatremia?
A. An older client with quadriplegia who is disoriented today.

B. An older client with influenza who vomited once today.
C. A client with diabetic ketoacidosis (DKA) who is sighing with rapid respirations.
D. A client who is receiving D5W in 0.45 NS one litter q12 hours postoperatively.
Answer: A. An older client with quadriplegia who is disoriented today.
Rationale:
An older client with quadriplegia has a limited ability to respond to stimuli, such as a decreased sense of
thirst which is an initial response to hypernatremia that manifests with mental confusion, is an early sign
of hypernatremia.
65. The practical nurse (PN) is reviewing the effects of nonsteroidal anti-inflammatory drugs (NSAIDs)
with a client who has acute gastritis. What information is correct about the action of NSAIDs?
A. Causes histamine receptor stimulation that increases the release of hydrochloric acid.
B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining.
C. Activates an inflammatory response which increases the drug's absorption.
D. Stimulates parietal cells to release pepsin leading to digestion of ingested foods.
Answer: B. Inhibits the synthesis of prostaglandins that normally protect the stomach lining.
Rationale:
NSAIDs inhibit the synthesis of prostaglandins which protect the stomach lining (B) leaving the gastric
mucosa more susceptible to damage. (A, C, and D) are incorrect.
66. The practical nurse (PN) is reinforcing the discharge instructions for a female client with cystitis.
Which statement indicates to the PN that the client understands measures to prevent urinary tract
infections (UTI)?
A. "I will limit my fluid intake to 1000 ml/day to prevent symptoms of frequency and urgency."
B. "Every 2 to 3 hours during waking hours, I will drink a glass of water and empty my bladder."
C. "I will use an antiseptic vaginal deodorant spray to reduce perineal bacterial growth."
D. "After each bowel movement, I will wash my perineal area with soap and water."
Answer: B. "Every 2 to 3 hours during waking hours, I will drink a glass of water and empty my bladder."
Rationale:
Measures to reduce the risk of UTI include liberal fluid intake, frequent bladder emptying, and hygienic
measures to prevent ascending bacterial contamination of the bladder. The client's statement that best

indicates understanding includes maintaining a regular and frequent fluid intake and urination every 2 to 3
hours during the day.
67. A client with atherosclerosis is trying to stop cigarette smoking and is using a nicotine patch. Which
information should the practical nurse (PN) reinforce with this client?
A. Abrupt discontinuation of the patch can cause high blood pressure.
B. Nausea and vomiting occur with abrupt discontinuation of the patch.
C. An increased risk for heart attack occurs with smoking while using the patch.
D. Smoking while using the patch increases the risk of a respiratory infection.
Answer: C. An increased risk for heart attack occurs with smoking while using the patch.
Rationale:
Nicotine in cigarette smoke along with the additive effect of the nicotine patch concomitantly increases
vasoconstriction and increases mean arterial pressure, which increases the risk for a myocardial infarction.
The priority is to reinforce the information about additional nicotine that contributes to hypertension.
68. The unlicensed assistive personnel (UAP) asks the practical nurse (PN) how to position a client for
tube feedings?
A. Elevate the head of the bed.
B. Use a Sims' position.
C. Place in a left lateral position.
D. Allow a position of comfort.
Answer: A. Elevate the head of the bed.
Rationale:
The head should be elevated 45 degrees before and one hour after feeding to reduce the possibility of
aspiration. The other options do not address the concept of safety and risk for aspiration.
69. The practical nurse (PN) is assessing a child who has a cast on the right lower leg. Which finding
should the PN report to the charge nurse?
A. Requests to wear socks over right foot.
B. Complaints of feeling hot.
C. An increased respiration rate.
D. A foul Odor from the cast's edge.

Answer: D. A foul Odor from the cast's edge.
Rationale:
Once a cast dries, warmth felt on the cast surface or foul smelling areas of the cast (D) may indicate
infection and should be reported. Although compromised neurovascular integrity may be manifested by
changes in temperature distal to the cast, the request to wear socks (A) or subjective complaints of feeling
hot (B) need further evaluation. An increased respiratory rate (C) may be related to anxiety and should be
evaluated with other vital signs.
70. The practical nurse (PN) is caring for a client in hospice who is comatose and needs vigorous
suctioning. The PN is conflicted about implementing the needed care. What ethical action should the PN
do first?
A. Ask for a different client care assignment.
B. Refer to the client's living will documentation.
C. Review the nursing code of ethics for guidance.
D. Speak with the unit supervisor about the problem.
Answer: D. Speak with the unit supervisor about the problem.
Rationale:
The first step in processing an ethical decision is clarification of one's personal values by discussing the
issue with other nurses, the unit supervisor, or the ethics committee.
71. The practical nurse (PN) is caring for a client who is receiving a therapeutic dose of warfarin
(Coumadin). The client asks the PN to explain the effect of eating green leafy vegetables. What
information should the PN provide?
A. The high content of vitamin K in green leafy vegetables decreases Coumadin's action.
B. Green vegetables are high in fibre and cellulose that decrease the absorption of Coumadin.
C. These foods have a natural anticoagulant effect that potentiates the effect of Coumadin.
D. Dietary intake of green leafy vegetables alters the bowel bacteria's production of vitamin K.
Answer: A. The high content of vitamin K in green leafy vegetables decreases Coumadin's action.
Rationale:
Coumadin works as an anticoagulant by blocking hepatic utilization of vitamin K in the production of
prothrombin, which is a component of the blood clotting cascade. Green leafy vegetables are high in
vitamin K, which counteracts the anticoagulant effect of Coumadin (A). (B, C, and D) are inaccurate.

72. An unlicensed assistive personnel (UAP) reports a blood pressure (BP) reading of 148/88 for a 10year-old child who is above the 95th percentile on the growth chart. What intervention should the practical
nurse (PN) implement?
A. Check the size of the blood pressure cuff used.
B. Instruct the UAP to repeat the BP measurement.
C. Ask about the child's activity prior to the measurement.
D. Review the child's history for evidence of renal disease.
Answer: A. Check the size of the blood pressure cuff used.
Rationale:
The size of a BP cuff should be checked (A) because a cuff that is too small for a child above the 95th
percentile is mostly likely to result in a falsely elevated reading. After evaluating the BP cuff size, the PN
should obtain the BP reading, not (B). The child's activity and history (C and D) are important, but the cuff
size should be determined to evaluate the accuracy of the BP measurement.
73. A 34-year-old male client who is admitted to the mental health unit for paranoia is responding to
antipsychotic medications. After the healthcare team decides to discharge the client, he tells the practical
nurse (PN) that his wife is unfaithful and he plans to "get her for this." How should the PN respond?
A. Report to the team that the client's wife should be informed.
B. Ask the client if he will comply with the mandatory day hospital visits.
C. Tell the client to discuss his medication dose with his healthcare provider.
D. Explain the consequences if he carries out his threats to his wife.
Answer: A. Report to the team that the client's wife should be informed.
Rationale:
Based on Tarasoff vs Regents of University of California (1970), the mental healthcare member has the
responsibility of "Duty to Warn" and report any intended, identified victim of possible future harm by a
client. The other options do not ensure the safety of the client or his wife.
74. A female client receives a new prescription for an oral contraceptive. Which information should the
practical nurse (PN) reinforce with the client?
A. Sit up for 30 minutes after ingestion.
B. Drink a glass of water with the medication.

C. Take the pill at the same time every day.
D. Avoid taking the medicine with grapefruit juice.
Answer: C. Take the pill at the same time every day.
Rationale:
An oral contraceptive should be taken at the same time every day (C) to maintain hormone levels and
provide the best effectiveness. (A and D) are not related to the use of oral contraceptives. Although
drinking a glass of water (B) is recommended with most oral medications, the client should understand the
importance for regular timing of administration of an oral contraceptive.
75. The practical nurse (PN) is caring for an older female client who has left-sided weakness after a
cerebrovascular accident. The client states that she wants to do her own sponge bath. Which action should
the PN implement?
A. Explain that the nurse should provide the bath to prevent extension of the CVA.
B. Provide the client with bath water and clean the area after self-care is completed.
C. Tell her to rest because the nurse's assistance will conserve her energy.
D. Encourage her to do what she can and assist her when she needs help.
Answer: D. Encourage her to do what she can and assist her when she needs help.
Rationale:
Encouraging the client to be as independent as possible, with assistance as needed, helps the client regain a
sense of independence and prevents problems associated with inactivity. The client should be encouraged
to do self-care as tolerated and assistance should be provided when the client is unable (D). (A) may instill
fear in the client and slow convalescence and rehabilitation. (B) does not provide the client support or
assistance that may be needed due to her hemiparesis. Although performing hygiene for the client may
conserve the client's energy (C), it does not promote client autonomy.
76. What action should the practical nurse (PN) implement first for a client with a head injury and clear
nasal drainage?
A. Obtain a specimen of the fluid for culture and sensitivity.
B. Check the nasal drainage with a glucose test strip.
C. Assess the client's temperature every 2 to 4 hours.
D. Inspect the nares bilaterally for signs of inflammation.
B. Check the nasal drainage with a glucose test strip.

Answer: B. Check the nasal drainage with a glucose test strip.
Rationale:
The PN needs to determine if the fluid is cerebrospinal fluid (CSF). Glucose is present in CSF, so the use
of a glucose test strip provides a quick bedside screen. If the nasal discharge is CSF, the client is at risk for
meningitis.
77. A client with acute pancreatitis has a low serum calcium level. The practical nurse (PN) observes that
the lips, nose, and side of the face contract after the client’s face is cleansed with a cloth. Which electronic
documentation describes these findings?
A. Bell's palsy noted.
B. Tic douloureux noted.
C. Chvostek's sign noted.
D. Trousseau's sign noted.
Answer: C. Chvostek's sign noted.
Rationale:
Chvostek’s sign (C) indicating low serum calcium is manifested by spasms of the muscles innervated by
the facial nerve, which is elicited by tapping the client’s face lightly below the temple. (A, B, and D) do
not describe this finding.
78. A mother calls the clinic to find out what she can do because a note from school has been sent about a
reported case of head lice in her child's class. What information should the practical nurse (PN) provide?
A. Wash your child's hair with permethrin 1% (Nix).
B. Cut your child's hair to an extremely short length.
C. Keep the child home from school for a week.
D. Tell the child to not share personal grooming items.
Answer: D. Tell the child to not share personal grooming items.
Rationale:
Primary prevention should be implemented and includes informing the parent about the mode of
transmission for head lice. The mother should instruct her child to not share personal grooming items (D)
because direct contact and shared objects play a role in the mode of transmission. (A) is implemented for a
child who has been diagnosed with an infestation. Short hair (B) does not prevent the spread of head lice
and is unnecessary. (C) is not indicated.

79. A client who delivered a 7 pound 8 ounce infant 3 hours ago has a soft, boggy uterus located above the
umbilicus. What action should the practical nurse implement next?
A. Perform fundal massage.
B. Notify the charge nurse.
C. Obtain a blood pressure.
D. Initiate perineal pad count.
Answer: A. Perform fundal massage.
Rationale:
A soft, boggy uterus places the client at increased risk for postpartum haemorrhage, so the PN should
perform fundal massage to contract the uterus.
80. The practical nurse (PN) is assisting an adult female client with perineal care. Which position should
the PN assist the client to take?
A. Prone.
B. Supine.
C. Side-lying.
D. Dorsal recumbent.
Answer: D. Dorsal recumbent.
Rationale:
To perform female perineal care, a client should be assisted to the dorsal recumbent position (D), which
provides visualization, comfort, and medical aseptic technique. (A and C) do not allow adequate
visualization and access to the anterior vulva. The supine position is the position of choice for performing
perineal care of the male (B), not the female.
81. A couple who are both carriers of the sickle cell trait ask the practical nurse (PN) to clarify their
children’s risk of inheriting this disease?
A. All of their children will be carriers of sickle cell trait.
B. Every fourth child will manifest the disease.
C. The risk levels for their children cannot be determined.
D. Each child has a 50% chance of being a carrier.
Answer: D. Each child has a 50% chance of being a carrier.

Rationale:
Sickle cell anaemia is an autosomal recessive disorder. With each conception, the chance of inheriting the
abnormal gene is calculated based on the pairing of parental genes. Both parents are carriers, so there is a
25% chance that each offspring will inherit the defective gene from both parents and manifest the disease,
a 50% risk of being a carrier (D), and 25% chance of inheriting the normal genes. (A, B, and C) are
inaccurate.
82. The practical nurse (PN) is reviewing dietary recommendations for a client who is newly diagnosed as
hypertensive. Which information is most important for the practical nurse (PN) to reinforce?
A. Check sodium content on all canned foods.
B. Recommend use of alcohol in moderation.
C. Use salt substitute as desired to enhance flavour.
D. Reduce fats by substituting fish for red meat.
Answer: A. Check sodium content on all canned foods.
Rationale:
The most valuable dietary modifications for a client with hypertension is reducing sodium intake. Canned
foods contain high levels of sodium, so the client should review the salt content on labels of canned
products and limit this intake.
83. A client with hypothyroidism receives a prescription for thyroid hormone replacement. Which sign(s)
of overdose should practical nurse (PN) reinforce with the client? (Select all that apply.) Select all that
apply
A. Weight gain.
B. Ataxia.
C. Bradycardia.
D. Nervousness.
E. Irritability.
F. Difficulty sleeping.
Answer: D. Nervousness.
E. Irritability.
F. Difficulty sleeping.
Rationale:

An overdose of thyroid hormone replacement mimics the signs and symptoms of hyperthyroidism, which
include nervousness, irritability, and insomnia. The other options are signs and symptoms of
hypothyroidism.
84. When taking the blood pressure of a client, how should the practical nurse (PN) position the client's
upper arm?
A. At the level of the heart.
B. Below the level of the heart.
C. Above the level of the heart.
D. Based on the client's preference.
Answer: A. At the level of the heart.
Rationale:
Taking a blood pressure at the level of the heart (A) provides the best and most consistent arterial blood
pressure reading. Positioning the arm below heart level (B) may result in a false high reading, and
positioning it above heart level (C) may result in a false low reading. (B, C, and D) should not be used
unless the client is unable to assume the best position.
85. Which site should the practical nurse (PN) avoid when administering IM immunizations to toddlers?
A. Ventrogluteal.
B. Dorsolateral.
C. Rectus femoris.
D. Vastus lateralis.
Answer: B. Dorsogluteal.
Rationale:
The IM dorsogluteal (B) site should be avoided in infants, toddlers, and smaller preschoolers due to the
risk of damaging the sciatic nerve. (A) is a smaller muscle mass that avoids the risk of nerve damage, but
is a preferable site when the gluteal muscles develop fully after walking. The anterior aspect of the thigh
(C) and vastus lateralis (D) are the preferred IM injection sites for infants and toddlers.
86. An infant is admitted to the hospital with a diagnosis of pyloric stenosis. Which finding should the
practical nurse (PN) expect to find in the client's history?
A. Loose, watery feces.

B. Red current stools.
C. Decreased appetite.
D. Projectile vomiting.
Answer: D. Projectile vomiting.
Rationale:
Projectile vomiting is a classic symptom of pyloric stenosis, which blocks the exit of gastric contents and
causes emesis to be vomited with considerable force. Other options are not characteristic with pyloric
stenosis.
87. An older male client who takes several medications comes to the clinic complaining of loss of appetite
and fatigue. He tells the practical nurse (PN), "Things look blurred, yellow, and sometimes have rings
around them." Which medication should be withheld until further assessment of laboratory tests is
obtained?
A. Digoxin (Lanoxin).
B. Ibuprofen (Motrin).
C. Potassium (K-Dur).
D. Hydralazine HCl (Apresoline).
Answer: A. Digoxin (Lanoxin).
Rationale:
Blurred, yellowed vision with halos, anorexia, and fatigue are common findings of digoxin toxicity (A).
Digoxin is used to manage heart failure, a common chronic illness in older clients. Although laboratory
studies may provide additional data about the client's complaints, ibuprofen (B), potassium (C), and
hydralazine (D) do not manifest these signs with toxicity.
88. A male client scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx
asks the practical nurse (PN) if he will ever be able to speak. Which response is best for the PN to provide?
A. Breathing occurs through a permanent neck opening which prevents normal speech.
B. Permanent removal of the voice box requires rehabilitation for esophageal speech.
C. Due to removal of the vocal cords, communication requires the use of sign language.
D. Once the breathing hole in the neck heals, the ability to speak requires a device.
Answer: B. Permanent removal of the voice box requires rehabilitation for esophageal speech.
Rationale:

The PN should inform the client that a total laryngectomy includes removal of the larynx and preepiglottis region resulting in a permanent tracheostomy and loss of normal speech abilities. Rehabilitation
is required to learn to speak using a voice prosthesis, esophageal speech or an electrolarynx.
89. A child with acute streptococcal pharyngitis is prescribed amoxicillin (Amoxil) suspension. The
mother asks the practical nurse (PN) when her child can return to school. Which information should the
PN provide?
A. After the child is evaluated for complications.
B. As soon as the child says the sore throat is better.
C. When the child completes 3 days of antibiotic doses.
D. After the child has taken antibiotics for 24 hours.
Answer: D. After the child has taken antibiotics for 24 hours.
Rationale:
Spread of infection of streptococcal disease is common in families, classrooms, and day care centers. After
24 hours of antibiotic therapy (D), the streptococcal infection should be noninfectious to others and the
child may return to school. (A and B) do not provide the parent with specific time frame. (C) is not
indicated.
90. For which client should the practical nurse implement the Glasgow Coma Scale (GCS) assessment?
A. A client with alcohol intoxication who mumbles in response to questions.
B. A client admitted with diabetic ketoacidosis and a blood glucose level of 400 mg/dl.
C. A client admitted with a seizure disorder who is started on a different anticonvulsant.
D. A client with a closed head injury who refuses to follow verbal commands.
Answer: D. A client with a closed head injury who refuses to follow verbal commands.
Rationale:
GCS evaluates the degree of consciousness impairment using the parameters of eye opening, verbal
response, and motor response in clients with head injuries. The client with a closed head injury who
refuses to follow verbal commands (D) should be assessed using the GCS to identify patterns of
neurological deterioration. (A, B, and C) are not candidates for this assessment.
91. What therapeutic response should the practical nurse (PN) monitor for in a client who is taking
medications for tuberculosis?

A. Cessation of a chronic cough.
B. Tolerance to medication regime.
C. Negative purified protein derivative (PPD) skin test.
D. Negative sputum cultures and chest xray.
Answer: D. Negative sputum cultures and chest xray.
Rationale:
Therapeutic effectiveness of antitubercular drugs is supported by clinical findings indicating negative
sputum cultures for the acid fast bacilli and improved chest radiographs. The other responses do not
indicate an effective therapeutic response.
92. After undergoing exploratory laparotomy and bowel resection, a client with a nasogastric tube (NGT)
to suction complains of nausea and stomach distention. The practical nurse (PN) irrigates the tube, but the
irrigating fluid does not return. What action should the PN implement?
A. Notify the healthcare provider.
B. Auscultate for bowel sounds.
C. Reposition the tube and check for placement.
D. Remove the tube and replace it with a new one.
Answer: C. Reposition the tube and check for placement.
Rationale:
Patency and position of a NGT are checked frequently to evaluate for dislodgement or NGT obstruction
with mucous, sediment, or blood clots. The NGT's placement should be verified and repositioned in the
stomach to obtain a return of the normal saline solution used to irrigate the NGT. The other options may
need to be implemented, but assessment and repositioning of the NGT in the stomach should be
implemented first.
93. Which action should the practical nurse implement to ensure that a hospitalized toddler takes a
prescribed dose of an oral medication?
A. Tell the child that the medication is candy and tastes good.
B. Reassure the child that it will make the child feel better right away.
C. Explain to the child firmly that the drug is important to take as soon as possible.
D. Convey to the child in simple terms what the medication is for and how it is given.
Answer: D. Convey to the child in simple terms what the medication is for and how it is given.

Rationale:
Explaining to the toddler what the drug is for and how it is given should be provided using simple
language and short sentences (D). (A, B, and C) are manipulative approaches that are not truthful and
should not be used with any client.
94. The practical nurse (PN) is caring for a client with chronic kidney disease (CKD). What information
should the PN reinforce about medication management?
A. Oral iron supplements reverse chronic anaemia in CKD.
B. Calcium supplements are needed to maintain serum levels.
C. Nonsteroidal anti-inflammatories are safe to use for pain.
D. Antihypertensive drugs should always be used as directed.
Answer: D. Antihypertensive drugs should always be used as directed.
Rationale:
Blood pressure control is essential for a client with CKD because hypertension and cardiovascular disease
occur with the progression of CKD. Other options are not indicated in CKD.
95. The practical nurse (PN) is monitoring a client who is admitted in active labor. After reviewing the
nursing admission assessment, the PN determines the client's membranes have been ruptured for 36 hours.
The PN should monitor the client for which risk factor?
A. Excessive bleeding.
B. Precipitous labor.
C. Supine hypotension.
D. Intrauterine infection.
Answer: D. Intrauterine infection.
Rationale:
When a client is in active labor with spontaneous rupture of membranes (SROM) longer than 24 hours,
microorganisms from the vagina can ascend into the amniotic sac and cause chorioamnionitis and
placentitis (D). Prolonged ROM is not associated with fetal or maternal bleeding (A). Although ROM may
increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor (B)
and has no correlation with supine hypotension (C).

96. The practical nurse (PN) is caring for a client with dementia. Which finding should the PN report to
the charge nurse that indicates the client's condition is getting worse?
A. Decreased agitation.
B. Fewer episodes of incontinence.
C. Spontaneous emotional responses.
D. Loss of contact with environment.
Answer: D. Loss of contact with environment.
Rationale:
Dementia is a client’s loss of cognitive abilities, including judgment, abstract thought, memory, language,
and the ability to think and understand the environment. An individual with dementia loses the ability to
recognize and respond to the environment as the disease progresses (D). The progression of dementia is
associated with increased agitation, not (A), and increased episodes of incontinence, not (B). Spontaneous
emotional response (C) is not indicative of deterioration in a client with dementia.
97. Which client is the best assignment for the practical nurse (PN)?
A. A client with renal failure and excessive peripheral edema.
B. A client with fluid overload who needs intravenous (IV) medication.
C. An older adult client with dehydration who needs assistance with feeding.
D. An older adult client with fluid volume deficit and a history of laxative abuse.
Answer: C. An older adult client with dehydration who needs assistance with feeding.
Rationale:
Client acuity determines client care assignments that should be aligned with the PN's scope of practice.
The best assignment for the PN in this group of clients is the client with non-complex health needs, such
as requiring assistance with nutrition and feeding.
98. At the scene of a motor vehicle collision, the practical nurse (PN) stops to render assistance to a victim
who has bleeding injuries of the face and neck. Which action should the PN implement after establishing
that the victim is unresponsive?
A. Deliver two mouth-to-mouth breaths.
B. Immobilize the head and neck.
C. Open the airway using jaw thrust method.
D. Clear the airway using a finger sweep.

Answer: B. Immobilize the head and neck.
Rationale:
Cervical spine trauma should be suspected in any client with significant upper torso, face, head, or neck
trauma, so cervical immobilization should be applied (B) prior to opening the airway (C) using the jaw
thrust, instead of the head tilt method. (A) occurs after absence of breathing is established. (D) is indicated
if a foreign body is visible and impedes rescue breathing.
99. An older male client with chronic pain due to degenerative joint disease frequently cries at night
because he cannot go to sleep. Which additional finding would the practical nurse (PN) mostly likely
observe in this client?
A. Changes in vital signs during episodes of pain.
B. Ability to localize painful and nonpainful areas.
C. Fatigue, depression, helplessness, and anger.
D. Pain relief when analgesics are staggered.
Answer: C. Fatigue, depression, helplessness, and anger.
Rationale:
Chronic pain affects an individual’s ability to cope, rest, or function independently and often manifests in
behavioral changes (C). Vital sign changes occur with acute pain (A), but chronic pain often persists or is
only partially relieved, causing minimal vital sign changes to occur as the body adapts its responses to
painful sympathetic stimulation. Chronic joint pain may be hard to localize (B) due to progressive changes
and persistent pain associated with degenerative joint disease. Although staggered doses of different
analgesics may reduce the client's pain, complete pain relief (D) does not commonly occur.
100. Which nursing action for a client who had a near-drowning experience is within the scope of the
practical nurse (PN)?
A. Collect arterial blood specimens and report ABG results to the healthcare provider.
B. Maintain cervical spine precautions during client transfers to a stretcher.
C. Coordinate transferring the client to another hospital using flight team support.
D. Assess lung sounds and neurological status for clarification with the family.
Answer: B. Maintain cervical spine precautions during client transfers to a stretcher.
Rationale:

Stabilizing the client's spine (B) during transfer to a stretcher is a basic nursing skill that is within the
scope of practice for a PN. Performing advanced procedures for arterial blood gases (ABG) analysis (A),
planning transport and care with a flight team (C), assessing, and clarifying client information with the
family (D), require the advanced skills and expertise of the registered nurse (RN).