,HESI PN Case Studies Exam Questions And Answers | Nursing |
2026/2027
1.** The PN observes bowel protruding through the client's abdominal
incision. What complication is the client most likely experiencing?
A) Wound infection
B) Wound dehiscence
C) Evisceration
D) Seroma formation
**Correct Answer:** C) Evisceration
**Rationale:** Evisceration occurs when internal organs (bowel) protrude
through a separated surgical wound. This is a surgical emergency requiring
immediate intervention. Dehiscence is separation of wound edges without
organ protrusion. Infection and seroma formation do not involve organ
protrusion.
---
**2.** Which assessment findings indicate the client is at risk for wound
dehiscence and evisceration? (Select all that apply.)
A) Age 72 years
B) Straining at stool
C) Colon resection surgery 8 days ago
D) Heart rate 102 bpm
E) Temperature 37.2°C
,**Correct Answer:** A, B, C
**Rationale:** Risk factors for wound dehiscence and evisceration include
advanced age, straining (which increases intra-abdominal pressure), and
recent abdominal surgery. Heart rate elevation and normal temperature are
not specific risk factors for this complication.
---
**3.** The PN notes that the client is straining at stool. Which instruction
should the PN reinforce with the client to prevent straining?
A) "Push harder to have a bowel movement."
B) "Use a stool softener as prescribed and avoid straining."
C) "Ignore the urge to have a bowel movement."
D) "Drink less fluid to reduce stool volume."
**Correct Answer:** B) "Use a stool softener as prescribed and avoid
straining."
**Rationale:** Straining increases intra-abdominal pressure, which can stress
the surgical incision and lead to dehiscence or evisceration. The client should
use stool softeners, increase fiber and fluid intake, and avoid straining.
---
### Part 2: Analyze Cues
, **4.** The PN observes the bowel protruding through the incision. What is
the priority nursing action?
A) Cover the wound with a dry sterile dressing
B) Apply sterile saline-soaked gauze and notify the provider immediately
C) Push the bowel back into the abdomen
D) Place the client in the Trendelenburg position
**Correct Answer:** B) Apply sterile saline-soaked gauze and notify the
provider immediately
**Rationale:** Evisceration is a surgical emergency. The PN should cover the
exposed bowel with sterile saline-soaked gauze to keep it moist, place the
client in a supine position with knees flexed to reduce intra-abdominal
pressure, and notify the provider immediately. The bowel should never be
pushed back into the abdomen.
---
**5.** The PN notifies the provider and prepares the client for emergency
surgery. Which finding would indicate the client is at increased risk for
complications?
A) The client reports mild anxiety
B) The client's bowel is pink and moist
C) The client's bowel is dusky and dry
D) The client's heart rate is 102 bpm
**Correct Answer:** C) The client's bowel is dusky and dry
2026/2027
1.** The PN observes bowel protruding through the client's abdominal
incision. What complication is the client most likely experiencing?
A) Wound infection
B) Wound dehiscence
C) Evisceration
D) Seroma formation
**Correct Answer:** C) Evisceration
**Rationale:** Evisceration occurs when internal organs (bowel) protrude
through a separated surgical wound. This is a surgical emergency requiring
immediate intervention. Dehiscence is separation of wound edges without
organ protrusion. Infection and seroma formation do not involve organ
protrusion.
---
**2.** Which assessment findings indicate the client is at risk for wound
dehiscence and evisceration? (Select all that apply.)
A) Age 72 years
B) Straining at stool
C) Colon resection surgery 8 days ago
D) Heart rate 102 bpm
E) Temperature 37.2°C
,**Correct Answer:** A, B, C
**Rationale:** Risk factors for wound dehiscence and evisceration include
advanced age, straining (which increases intra-abdominal pressure), and
recent abdominal surgery. Heart rate elevation and normal temperature are
not specific risk factors for this complication.
---
**3.** The PN notes that the client is straining at stool. Which instruction
should the PN reinforce with the client to prevent straining?
A) "Push harder to have a bowel movement."
B) "Use a stool softener as prescribed and avoid straining."
C) "Ignore the urge to have a bowel movement."
D) "Drink less fluid to reduce stool volume."
**Correct Answer:** B) "Use a stool softener as prescribed and avoid
straining."
**Rationale:** Straining increases intra-abdominal pressure, which can stress
the surgical incision and lead to dehiscence or evisceration. The client should
use stool softeners, increase fiber and fluid intake, and avoid straining.
---
### Part 2: Analyze Cues
, **4.** The PN observes the bowel protruding through the incision. What is
the priority nursing action?
A) Cover the wound with a dry sterile dressing
B) Apply sterile saline-soaked gauze and notify the provider immediately
C) Push the bowel back into the abdomen
D) Place the client in the Trendelenburg position
**Correct Answer:** B) Apply sterile saline-soaked gauze and notify the
provider immediately
**Rationale:** Evisceration is a surgical emergency. The PN should cover the
exposed bowel with sterile saline-soaked gauze to keep it moist, place the
client in a supine position with knees flexed to reduce intra-abdominal
pressure, and notify the provider immediately. The bowel should never be
pushed back into the abdomen.
---
**5.** The PN notifies the provider and prepares the client for emergency
surgery. Which finding would indicate the client is at increased risk for
complications?
A) The client reports mild anxiety
B) The client's bowel is pink and moist
C) The client's bowel is dusky and dry
D) The client's heart rate is 102 bpm
**Correct Answer:** C) The client's bowel is dusky and dry
