HESI PN106 Fundamentals of Nursing 44047 Fall 2025 at Nightingale College
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Free HESI PN106 Fundamentals of Nursing 44047 Fall 2025 at Nightingale College Questions
At 2100, an older adult client turns on the call light and reports to the practical nurse (PN) the inability to fall asleep. Which is the priority nursing action?
- Provide a PRN hypnotic medication.
- Evaluate the room environment.
- Reassure the client that it is still early.
- Close the door to the client's room.
Explanation
The priority action is to evaluate the room environment to ensure that it is conducive to sleep. Factors such as lighting, noise, temperature, or discomfort may be affecting the client's ability to fall asleep. By addressing environmental factors, the PN can help create a more restful setting for the client, potentially improving sleep without the need for medications. This step is non-invasive and helps promote a natural sleep environment.
A client with fecal incontinence has inflamed skin around the rectal area. Following an episode of incontinence, how should the practical nurse (PN) care for this area?
- Spray the area with a mild periwash solution.
- Rinse the inflamed area with dilute hydrogen peroxide.
- Gently massage around the outside of the reddened area.
- Apply a thick coating of antibiotic ointment.
Explanation
A mild periwash solution is commonly used to cleanse the area around the rectum in clients with fecal incontinence, especially if there is skin irritation. These solutions are gentle and help to clean the area without causing further irritation to the inflamed skin. After cleansing, it’s important to pat the area dry and possibly apply a protective barrier cream to prevent further irritation.
The practical nurse (PN) is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the PN implement?
- Remove nasal cannula
- Increase the oxygen to 3 L/minute.
- Verify placement of pulse oximeter.
- Switch to a nonrebreather mask.
Explanation
An oxygen saturation level of 89% is below the normal range (usually 92-100%), indicating that the client may not be receiving enough oxygen. A nonrebreather mask can deliver higher concentrations of oxygen compared to a nasal cannula, providing immediate and more effective oxygenation for clients with low oxygen saturation. The PN should switch to a nonrebreather mask to help increase the oxygen levels and improve the client’s saturation.
When making the bed of a client who needs a bed cradle, which action should the practical nurse (PN) include?
- Drape the top sheet and covers loosely over the bed cradle.
- Tell the client to call for help before getting out of bed.
- Keep both the upper and lower side rails in a raised position.
- Keep the bed in the lowest position while changing the sheets.
Explanation
When using a bed cradle, the top sheet and covers should be draped loosely over the cradle to prevent pressure on the client’s body. The bed cradle is used to keep the bedding from touching or putting pressure on areas of the body that may be injured, painful, or prone to skin breakdown. Loosely draping the bedding allows the client comfort while still providing the necessary protection.
NPO. Ice chips only PRN. Ondansetron (Zofran) 3 mg IM q4 hours PRN vomiting. 0.9 % sodium chloride solution 1,000 ml per infusion pump at 120 ml/hour. Serum electrolytes q AM. After reviewing the medication administration record (MAR) prescriptions above, the practical nurse (PN) retrieves "Ondansetron Injection, USP 4 mg/2 mL" from the unit's automated medication dispensing system, for a client who is vomiting. When preparing to administer the medication, the PN scans the vial's bar code at the bedside and a dosage pop-up appears on the computer screen. Which action should the PN take?
- A Rescan the vial label until the system accepts bar code.
- B Prepare another dosage that matches the vial label 4 mg/2 mL.
- C Enter 3 mg (1.5 mL) as the prepared dose for administration.
- D Call the pharmacy to report a dose discrepancy in the pop-up.
Explanation
The medication prescription specifies a dose of 3 mg of Ondansetron, but the vial contains 4 mg in 2 mL. To administer the correct dose of 3 mg, the PN should prepare 1.5 mL of the solution. The system may have a pop-up dosage discrepancy because it is calculating the full vial concentration, but the PN should manually enter the correct dose (3 mg or 1.5 mL) to ensure the patient receives the proper amount of medication.
The practical nurse (PN) is working in a surgical preoperative area and reviewing a signed consent form. The form reads "Amputation of the right lower leg," but the client's left leg is labeled for amputation. The client has already received the preoperative medication from the anesthesiologist. Which should be the PN's next action?
- Contact the healthcare provider to reschedule the surgery.
- Obtain verbal consent from the client's nearest relative or significant other.
- Transport the client to the surgery suite since medications were administered.
- Cross out the error and initial the form to ensure the correct surgery.
Explanation
The PN should immediately contact the healthcare provider to address the error on the consent form and ensure that the correct surgery is performed. Since the form incorrectly states "amputation of the right lower leg" while the left leg is labeled for amputation, this is a critical issue that must be resolved before proceeding. The healthcare provider should be informed, and the surgery should be rescheduled if necessary to ensure proper documentation and patient safety.
The practical nurse (PN) is administering an analgesic to a client with low back pain. To promote the effectiveness of the medication, which is the best intervention for the PN to implement?
- Reposition the client with proper alignment and massage the lower back.
- Encourage the client to take deep breaths and to ambulate frequently.
- Assist the client to perform active range of motion and back exercises.
- Force fluids and progress diet to include milk products.
Explanation
To promote the effectiveness of the analgesic, proper positioning and alignment are key. Repositioning the client with proper alignment can help relieve pressure on the back, reduce discomfort, and support the healing process. Additionally, gentle massage of the lower back can improve circulation, reduce muscle tension, and enhance the pain relief provided by the medication.
The practical nurse (PN) is measuring the vital signs of an older adult. When attempting to measure the client's radial pulse rate, the PN palpates the pulse but is unable to feel the pulse long enough to count the rate. Which action should the PN take?
- Attempt to palpate the ulnar pulse on the same arm.
- Reduce pressure at the site to prevent occlusion.
- Elevate the hand to increase the pulse strength.
- Notify the charge nurse of the absence of the pulse.
Explanation
When palpating the radial pulse, the PN may inadvertently apply too much pressure, which can occlude the pulse, making it difficult to feel long enough to count. By reducing the pressure at the site, the blood flow will be better felt, and the pulse can be more easily assessed. This is the most appropriate action to take when having difficulty palpating the radial pulse.
Which information should the practical nurse (PN) include in a report of a client being admitted to the rehabilitation unit from the nursing home? Select all that apply.
- Admitting diagnosis.
- Nursing home care plan.
- Residency status.
- Current code status.
- Insurance coverage.
Explanation
Correct Answer Is:
A. Admitting diagnosis. B. Nursing home care plan. D. Current code status.
A. Admitting diagnosis: The PN should include the admitting diagnosis in the report to ensure that the healthcare team is aware of the reason for the client's admission to the rehabilitation unit. This helps guide the care plan and ensures appropriate treatment.
B. Nursing home care plan: The nursing home care plan is important for providing continuity of care. Including this information helps the rehabilitation team understand the client’s prior care needs, ongoing goals, and any specific interventions that may be necessary.
D. Current code status: Current code status is essential information for the rehabilitation team to know. It indicates the client's wishes regarding resuscitation or life-saving measures in the event of a medical emergency, and ensures that care is aligned with the client’s preferences.
The spouse of a client who has just been diagnosed with stage 5 metastatic cancer shouted, "This is absurd! I want to talk to the doctor right now!" The practical nurse (PN) should consider which stage of the grieving process in order to respond best to the spouse's comment? Options:
- Conversion reaction.
- Bargaining.
- Anger.
- Intellectualization.
Explanation
The spouse’s reaction of shouting, "This is absurd! I want to talk to the doctor right now!" reflects a typical emotional response of anger. Anger is one of the stages in the grieving process, as described by Elisabeth Kübler-Ross in her model of the five stages of grief. In this stage, individuals may feel intense frustration or rage, often directed at the situation, healthcare providers, or loved ones, as they struggle to accept the diagnosis. The spouse’s outburst is a clear demonstration of anger in response to the overwhelming news of a serious illness.
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