Med-Surg Hesi PN
A 70-year-old client status post hip replacement is transferred to a rehabilitation facility. Which
scale should the practical nurse (PN) identify as the best tool to predict the client's risk for
developing skin breakdown?
a. Braden Scale
b. Morse Scale
c. Aldrete Scale
d. Wong-Baker Face Scale - ANS - a. Braden Scale
The Braden Scale is made up of six subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction and shear. A hospitalized adult with a score 16 or below or an older adult
with a score of 18 or below is at an increased risk for skin breakdown.
\A client comes to the clinic and reports the presence of a painful lesion in the genital area; they
described it as a blister 2 days earlier that is now crusty. Which intervention should the practical
nurse (PN) implement first?
a. Ask the client if they have had unprotected sex.
b. Prepare the client for a culture and sensitivity test of the lesion.
c. Inform the client this occurrence will have to be reported to the public health department.
d. Prepare to administer penicillin intramuscularly into the dorsogluteal area. - ANS - a. Ask the
client if they have had unprotected sex.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted
disease (STD), so the PN should ask the client if they had unprotected sex and if the client has
exposed others to the disease.
\A client demonstrated pupillary constriction when a pen light was shined in their eyes. Which
nursing action should the practical nurse perform?
a. Report the finding to the health care provider.
b. Record the finding on the assessment notes.
c. Assess blood pressure to rule out hypertension.
d. Record that the client has poor vision. - ANS - b. Record the finding on the assessment
notes.
Pupillary constriction to light is a normal finding and should be documented in the assessment
notes.
\A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal
area. The practical nurse (PN) should observe this client for which problem during the early
post-therapy days?
a. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS - b. Headache
,Rationale:
Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation
of surrounding brain tissue, swelling, headache, and fatigue.
\A client diagnosed with a fracture of the left radius has a plaster cast applied. The nurse has
reinforced instructions for drying the cast over the next 24 hours. Which statement by the client
indicates the teaching was effective?
a. "I will wrap the cast in plastic wrap for 24 hours."
b. "I will support the cast on a firm surface during the night."
c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium setting until the plaster cast feels dry to the touch." - ANS
- c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air."
Rationale:
The nurse should instruct the client to keep the cast exposed to circulating air and avoid
covering it with material that might keep it moist.
\A client diagnosed with a skull hematoma and fractured left (L) clavicle following a six foot fall
from a ladder is admitted to the unit. Which sign should the practical nurse (PN) report
immediately?
a. Spontaneously opens eyes.
b. Obeys commands in movement and grip.
c. Answers questions, but is confused.
d. Has abnormal flexion or extension of (L) arm. - ANS - c. Answers questions, but is confused.
Rationale:
Confusion following a head injury is usually the first sign of increased intracranial pressure.
\A client diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro
checks every 2 hours. Which manifestation would the practical nurse monitor for that would
provide the first indication of altered neurological function?
a. Change in level of consciousness
b. Increasing muscular weakness
c. Changes in pupil size bilaterally
d. Progressive nuchal rigidity - ANS - a. Change in level of consciousness
A decrease or change in the level of consciousness is usually the first indication of neurological
deterioration.
\A client diagnosed with chronic obstructive pulmonary disease complains to the practical nurse
of extreme fatigue after coughing. Which self-care measures can help minimize the client's
dyspnea? (Select all that apply.)
a. Assume a sitting position with shoulders relaxed and knees flexed.
b. Support forearms with a pillow and place both feet flat on the floor.
c. Slightly drop the head, bend forward, and slowly exhale with pursed lips.
d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply.
e. Repeat inhaling deeply and slowly with pursed lips while bending forward only once.
f. Repeat exhaling and wait for the cough reflex to facilitate movement of the secretions.
g. After coughing, inhale deeply from abdomen and cough three or four times while exhaling. -
ANS - a. Assume a sitting position with shoulders relaxed and knees flexed.
, b. Support forearms with a pillow and place both feet flat on the floor.
c. Slightly drop the head, bend forward, and slowly exhale with pursed lips.
d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply.
Effective coughing can help the client to cough secretions, therefore improving gas exchange
and minimize fatigue. The client should assume the sitting position with shoulders relaxed and
knees flexed. Their forearms should be supported with a pillow and both feet place flat on the
floor. The client should slightly drop their head, bent forward, and slowly exhale through pursed
lips using slow and deep diaphragmatic breathing to help facilitate effective coughing. The client
should repeat the previous steps two or three times. The client should initiate the cough reflex,
not wait for it. The client should also take a deep abdominal breath before initiating a cough.
\A client diagnosed with diabetic neuropathy has a nonhealing ulcer on the lateral aspect of their
right (R) foot. Which question should the practical nurse (PN) ask to gather objective data for
the development of a diabetic foot care teaching plan?
a. Ask the client how they examine their feet.
b. Ask which hypoglycemic medication they take.
c. Ask to look at the pair of shoes they wear.
d. Ask how long they have been diagnosed with diabetes mellitus. - ANS - c. Ask to look at the
pair of shoes they wear.
Rationale:
Asking to look at the client's shoes will give the most objective data. The PN needs to inspect
the client's shoes' inside for any area such as a seam that may be rubbing against the client foot
causing trauma to their feet. Well-fitted shoes are very important to prevent the development of
foot ulcers for the diabetic client.
\A client diagnosed with duodenal ulcers is admitted to the hospital. The client was administered
ranitidine hydrochloride 150 mg PO at bedtime. Which finding would indicate a therapeutic
response of the medication?
a. Gastric secretions pH level below 3.
b. Hemoccult testing is positive on two different occasions.
c. No difficulty falling asleep reported.
d. No complaints of abdominal pain or heartburn verbalized. - ANS - d. No complaints of
abdominal pain or heartburn verbalized.
Rationale:
Lack of abdominal pain within 4 hours after meals indicates decreased duodenal irritation, a
positive outcome in the treatment of duodenal ulcer.
\A client diagnosed with emphysema that is oxygen-dependent lives alone at home and
manages self-care with no difficulty. Which finding should prompt the home health practical
nurse to consult the registered nurse case manager?
a. A pulse oximetry reading of 91% on oxygen at 2 L/m
b. A weight loss of 5 pounds since the last monthly home visit
c. The client reports feeling as tired as at the last visit by the nurse
d. Upon entering the home, the PN noticed dirty dishes and clothing scattered around the home.
- ANS - b. A weight loss of 5 pounds since the last monthly home visit
A 70-year-old client status post hip replacement is transferred to a rehabilitation facility. Which
scale should the practical nurse (PN) identify as the best tool to predict the client's risk for
developing skin breakdown?
a. Braden Scale
b. Morse Scale
c. Aldrete Scale
d. Wong-Baker Face Scale - ANS - a. Braden Scale
The Braden Scale is made up of six subscales: sensory perception, moisture, activity, mobility,
nutrition, and friction and shear. A hospitalized adult with a score 16 or below or an older adult
with a score of 18 or below is at an increased risk for skin breakdown.
\A client comes to the clinic and reports the presence of a painful lesion in the genital area; they
described it as a blister 2 days earlier that is now crusty. Which intervention should the practical
nurse (PN) implement first?
a. Ask the client if they have had unprotected sex.
b. Prepare the client for a culture and sensitivity test of the lesion.
c. Inform the client this occurrence will have to be reported to the public health department.
d. Prepare to administer penicillin intramuscularly into the dorsogluteal area. - ANS - a. Ask the
client if they have had unprotected sex.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted
disease (STD), so the PN should ask the client if they had unprotected sex and if the client has
exposed others to the disease.
\A client demonstrated pupillary constriction when a pen light was shined in their eyes. Which
nursing action should the practical nurse perform?
a. Report the finding to the health care provider.
b. Record the finding on the assessment notes.
c. Assess blood pressure to rule out hypertension.
d. Record that the client has poor vision. - ANS - b. Record the finding on the assessment
notes.
Pupillary constriction to light is a normal finding and should be documented in the assessment
notes.
\A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal
area. The practical nurse (PN) should observe this client for which problem during the early
post-therapy days?
a. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS - b. Headache
,Rationale:
Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation
of surrounding brain tissue, swelling, headache, and fatigue.
\A client diagnosed with a fracture of the left radius has a plaster cast applied. The nurse has
reinforced instructions for drying the cast over the next 24 hours. Which statement by the client
indicates the teaching was effective?
a. "I will wrap the cast in plastic wrap for 24 hours."
b. "I will support the cast on a firm surface during the night."
c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium setting until the plaster cast feels dry to the touch." - ANS
- c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air."
Rationale:
The nurse should instruct the client to keep the cast exposed to circulating air and avoid
covering it with material that might keep it moist.
\A client diagnosed with a skull hematoma and fractured left (L) clavicle following a six foot fall
from a ladder is admitted to the unit. Which sign should the practical nurse (PN) report
immediately?
a. Spontaneously opens eyes.
b. Obeys commands in movement and grip.
c. Answers questions, but is confused.
d. Has abnormal flexion or extension of (L) arm. - ANS - c. Answers questions, but is confused.
Rationale:
Confusion following a head injury is usually the first sign of increased intracranial pressure.
\A client diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro
checks every 2 hours. Which manifestation would the practical nurse monitor for that would
provide the first indication of altered neurological function?
a. Change in level of consciousness
b. Increasing muscular weakness
c. Changes in pupil size bilaterally
d. Progressive nuchal rigidity - ANS - a. Change in level of consciousness
A decrease or change in the level of consciousness is usually the first indication of neurological
deterioration.
\A client diagnosed with chronic obstructive pulmonary disease complains to the practical nurse
of extreme fatigue after coughing. Which self-care measures can help minimize the client's
dyspnea? (Select all that apply.)
a. Assume a sitting position with shoulders relaxed and knees flexed.
b. Support forearms with a pillow and place both feet flat on the floor.
c. Slightly drop the head, bend forward, and slowly exhale with pursed lips.
d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply.
e. Repeat inhaling deeply and slowly with pursed lips while bending forward only once.
f. Repeat exhaling and wait for the cough reflex to facilitate movement of the secretions.
g. After coughing, inhale deeply from abdomen and cough three or four times while exhaling. -
ANS - a. Assume a sitting position with shoulders relaxed and knees flexed.
, b. Support forearms with a pillow and place both feet flat on the floor.
c. Slightly drop the head, bend forward, and slowly exhale with pursed lips.
d. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply.
Effective coughing can help the client to cough secretions, therefore improving gas exchange
and minimize fatigue. The client should assume the sitting position with shoulders relaxed and
knees flexed. Their forearms should be supported with a pillow and both feet place flat on the
floor. The client should slightly drop their head, bent forward, and slowly exhale through pursed
lips using slow and deep diaphragmatic breathing to help facilitate effective coughing. The client
should repeat the previous steps two or three times. The client should initiate the cough reflex,
not wait for it. The client should also take a deep abdominal breath before initiating a cough.
\A client diagnosed with diabetic neuropathy has a nonhealing ulcer on the lateral aspect of their
right (R) foot. Which question should the practical nurse (PN) ask to gather objective data for
the development of a diabetic foot care teaching plan?
a. Ask the client how they examine their feet.
b. Ask which hypoglycemic medication they take.
c. Ask to look at the pair of shoes they wear.
d. Ask how long they have been diagnosed with diabetes mellitus. - ANS - c. Ask to look at the
pair of shoes they wear.
Rationale:
Asking to look at the client's shoes will give the most objective data. The PN needs to inspect
the client's shoes' inside for any area such as a seam that may be rubbing against the client foot
causing trauma to their feet. Well-fitted shoes are very important to prevent the development of
foot ulcers for the diabetic client.
\A client diagnosed with duodenal ulcers is admitted to the hospital. The client was administered
ranitidine hydrochloride 150 mg PO at bedtime. Which finding would indicate a therapeutic
response of the medication?
a. Gastric secretions pH level below 3.
b. Hemoccult testing is positive on two different occasions.
c. No difficulty falling asleep reported.
d. No complaints of abdominal pain or heartburn verbalized. - ANS - d. No complaints of
abdominal pain or heartburn verbalized.
Rationale:
Lack of abdominal pain within 4 hours after meals indicates decreased duodenal irritation, a
positive outcome in the treatment of duodenal ulcer.
\A client diagnosed with emphysema that is oxygen-dependent lives alone at home and
manages self-care with no difficulty. Which finding should prompt the home health practical
nurse to consult the registered nurse case manager?
a. A pulse oximetry reading of 91% on oxygen at 2 L/m
b. A weight loss of 5 pounds since the last monthly home visit
c. The client reports feeling as tired as at the last visit by the nurse
d. Upon entering the home, the PN noticed dirty dishes and clothing scattered around the home.
- ANS - b. A weight loss of 5 pounds since the last monthly home visit
