HESI PN MED SURG EXIT EXAM / MED
SURG HESI PN
A 70-yr-antique patron reputation put up hip alternative is transferred to a rehabilitation facility.
Which scale must the practical nurse (PN) discover because the exceptional device to are
expecting 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 of six subscales: sensory notion, moisture, hobby, mobility, nutrition,
and friction and shear. A hospitalized adult with a rating 16 or underneath or an older person
with a score of 18 or under is at an accelerated danger for skin breakdown.
A purchaser comes to the sanatorium and reports the presence of a painful lesion in the genital
area; they defined it as a blister 2 days earlier that is now crusty. Which intervention ought to the
practical nurse (PN) put in force first?
A. Ask the patron in the event that they have had unprotected sex.
B. Prepare the consumer for a lifestyle and sensitivity check of the lesion.
C. Inform the patron this occurrence will have to be said to the general public fitness
department.
D. Prepare to manage penicillin intramuscularly into the dorsogluteal place. - ANS-a. Ask the
client if they have had unprotected intercourse.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted
sickness (STD), so the PN should ask the purchaser if they had unprotected sex and if the
patron has exposed others to the ailment.
A consumer validated pupillary constriction while a pen light was shined in their eyes. Which
nursing movement need to the sensible nurse perform?
A. Report the finding to the fitness care company.
B. Record the locating on the assessment notes.
C. Assess blood stress to rule out high blood pressure.
D. Record that the customer has terrible vision. - ANS-b. Record the finding at the assessment
notes.
,Pupillary constriction to mild is a everyday finding and ought to be documented within the
assessment notes.
A consumer recognized with a mind tumor is receiving radiation beam treatments to the proper
frontal vicinity. The practical nurse (PN) need to take a look at this customer for which problem
throughout the early publish-therapy days?
A. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a local remedy, and maximum side results are web page-precise, along with
irritation of surrounding brain tissue, swelling, headache, and fatigue.
A patron recognized with a fracture of the left radius has a plaster forged carried out. The nurse
has strengthened commands for drying the cast over the subsequent 24 hours. Which
declaration by way of the purchaser shows the coaching changed into powerful?
A. "I will wrap the forged in plastic wrap for 24 hours."
b. "I will support the solid on a company surface at some point of the night."
c. "I will no longer cover it; as a substitute I'll preserve the solid surfaces exposed to circulating
air."
d. "I can use a blow dryer on medium placing until the plaster solid feels dry to touch." - ANS-c.
"I will not cover it; as a substitute I'll preserve the solid surfaces exposed to circulating air."
Rationale:
The nurse have to instruct the patron to preserve the cast exposed to circulating air and avoid
overlaying it with cloth that could keep it moist.
A client identified with a fracture of the left radius has a plaster forged carried out. The nurse
has strengthened instructions for drying the solid over the subsequent 24 hours. Which
declaration via the purchaser suggests the teaching was effective?
A. "I will wrap the solid in plastic wrap for twenty-four hours."
b. "I will support the cast on a company floor all through the night."
c. "I will now not cover it; alternatively I'll keep the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium placing till the plaster forged feels dry to the touch." -
ANS-c. "I will no longer cowl it; as a substitute I'll maintain the forged surfaces uncovered to
circulating air."
Rationale:
,The nurse must educate the client to hold the cast exposed to circulating air and keep away
from protecting it with fabric that would preserve 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 have to the practical nurse (PN) report right
now?
A. Spontaneously opens eyes.
B. Obeys instructions in movement and grip.
C. Answers questions, but is pressured.
D. Has abnormal flexion or extension of (L) arm. - ANS-c. Answers questions, but is stressed.
Rationale:
Confusion following a head harm is commonly the first sign of expanded intracranial pressure.
A patron identified with bacterial meningitis is admitted to the unit and is prescribed neuro
exams each 2 hours. Which manifestation would the practical nurse screen for that might offer
the primary indication of altered neurological function?
A. Change in level of awareness
b. Increasing muscular weakness
c. Changes in scholar length bilaterally
d. Progressive nuchal tension - ANS-a. Change in degree of attention
A lower or alternate inside the stage of attention is generally the first indication of neurological
deterioration.
A purchaser diagnosed with chronic obstructive pulmonary ailment complains to the practical
nurse of excessive fatigue after coughing. Which self-care measures can help minimize the
consumer's dyspnea? (Select all that practice.)
a. Assume a sitting role with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and vicinity both feet flat on the ground.
C. Slightly drop the top, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up instantly, the use of diaphragmatic respiration to inhale slowly and deeply.
E. Repeat breathing in deeply and slowly with pursed lips even as bending forward handiest
once.
F. Repeat exhaling and watch for the cough reflex to facilitate movement of the secretions.
G. After coughing, inhale deeply from abdomen and cough 3 or 4 times while exhaling. - ANS-a.
Assume a sitting position with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and place both toes flat at the ground.
C. Slightly drop the top, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up immediately, the use of diaphragmatic respiratory to inhale slowly and
deeply.
, Effective coughing can help the customer to cough secretions, therefore enhancing gas trade
and reduce fatigue. The patron have to assume the sitting position with shoulders comfortable
and knees flexed. Their forearms have to be supported with a pillow and both feet area flat at
the ground. The consumer should barely drop their head, bent forward, and slowly exhale via
pursed lips the usage of gradual and deep diaphragmatic respiratory to help facilitate powerful
coughing. The patron ought to repeat the previous steps or 3 instances. The consumer must
initiate the cough reflex, now not wait for it. The customer ought to additionally take a deep
abdominal breath before starting up a cough.
A client diagnosed with congestive coronary heart failure has developed growing pedal edema
and pulmonary edema. What nutritional modification is most vital for the realistic nurse (PN) to
enhance with this client?
A. Avoid excessive carbohydrate ingredients.
B. Decrease consumption of fat-soluble vitamins.
C. Decrease caloric consumption.
D. Restrict salt and fluid consumption. - ANS-d. Restrict salt and fluid intake.
Rationale:
Salt and fluid regulations are the first nutritional adjustments for a client who is retaining fluid as
manifested by edema and pulmonary edema.
A customer recognized with diabetes has a prescription of 5 gadgets of ordinary insulin and 15
units of NPH insulin. In which order ought to the realistic nurse put together to manage the
insulin?List in order the nursing actions to be accomplished.
Arrange the sequence alternatives in the appropriate order through assigning every option a
number of.
Perform hand hygiene according to facility policy.
Inject 5 gadgets of air into ordinary insulin vial.
Inspect insulin vials for type and expiration dates.
Inject 15 units of air into NPH insulin vial.
Withdraw 15 devices of NPH insulin from vial.
Withdraw 5 devices of ordinary insulin from vial. - ANS-1. Perform hand hygiene consistent with
facility coverage.
2. Inspect insulin vials for type and expiration dates.
3. Inject 15 gadgets of air into NPH insulin vial.
4. Inject 5 gadgets of air into ordinary insulin vial.
Five. Withdraw five gadgets of everyday insulin from vial.
6. Withdraw 15 devices of NPH insulin from vial.
Rationale:
The first nursing action is to perform hand hygiene. The subsequent motion is to inspect vials for
type and expiration dates after which add 15 gadgets of air to NPH insulin vial. Next upload 5
SURG HESI PN
A 70-yr-antique patron reputation put up hip alternative is transferred to a rehabilitation facility.
Which scale must the practical nurse (PN) discover because the exceptional device to are
expecting 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 of six subscales: sensory notion, moisture, hobby, mobility, nutrition,
and friction and shear. A hospitalized adult with a rating 16 or underneath or an older person
with a score of 18 or under is at an accelerated danger for skin breakdown.
A purchaser comes to the sanatorium and reports the presence of a painful lesion in the genital
area; they defined it as a blister 2 days earlier that is now crusty. Which intervention ought to the
practical nurse (PN) put in force first?
A. Ask the patron in the event that they have had unprotected sex.
B. Prepare the consumer for a lifestyle and sensitivity check of the lesion.
C. Inform the patron this occurrence will have to be said to the general public fitness
department.
D. Prepare to manage penicillin intramuscularly into the dorsogluteal place. - ANS-a. Ask the
client if they have had unprotected intercourse.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted
sickness (STD), so the PN should ask the purchaser if they had unprotected sex and if the
patron has exposed others to the ailment.
A consumer validated pupillary constriction while a pen light was shined in their eyes. Which
nursing movement need to the sensible nurse perform?
A. Report the finding to the fitness care company.
B. Record the locating on the assessment notes.
C. Assess blood stress to rule out high blood pressure.
D. Record that the customer has terrible vision. - ANS-b. Record the finding at the assessment
notes.
,Pupillary constriction to mild is a everyday finding and ought to be documented within the
assessment notes.
A consumer recognized with a mind tumor is receiving radiation beam treatments to the proper
frontal vicinity. The practical nurse (PN) need to take a look at this customer for which problem
throughout the early publish-therapy days?
A. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANS-b. Headache
Rationale:
Radiotherapy is a local remedy, and maximum side results are web page-precise, along with
irritation of surrounding brain tissue, swelling, headache, and fatigue.
A patron recognized with a fracture of the left radius has a plaster forged carried out. The nurse
has strengthened commands for drying the cast over the subsequent 24 hours. Which
declaration by way of the purchaser shows the coaching changed into powerful?
A. "I will wrap the forged in plastic wrap for 24 hours."
b. "I will support the solid on a company surface at some point of the night."
c. "I will no longer cover it; as a substitute I'll preserve the solid surfaces exposed to circulating
air."
d. "I can use a blow dryer on medium placing until the plaster solid feels dry to touch." - ANS-c.
"I will not cover it; as a substitute I'll preserve the solid surfaces exposed to circulating air."
Rationale:
The nurse have to instruct the patron to preserve the cast exposed to circulating air and avoid
overlaying it with cloth that could keep it moist.
A client identified with a fracture of the left radius has a plaster forged carried out. The nurse
has strengthened instructions for drying the solid over the subsequent 24 hours. Which
declaration via the purchaser suggests the teaching was effective?
A. "I will wrap the solid in plastic wrap for twenty-four hours."
b. "I will support the cast on a company floor all through the night."
c. "I will now not cover it; alternatively I'll keep the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium placing till the plaster forged feels dry to the touch." -
ANS-c. "I will no longer cowl it; as a substitute I'll maintain the forged surfaces uncovered to
circulating air."
Rationale:
,The nurse must educate the client to hold the cast exposed to circulating air and keep away
from protecting it with fabric that would preserve 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 have to the practical nurse (PN) report right
now?
A. Spontaneously opens eyes.
B. Obeys instructions in movement and grip.
C. Answers questions, but is pressured.
D. Has abnormal flexion or extension of (L) arm. - ANS-c. Answers questions, but is stressed.
Rationale:
Confusion following a head harm is commonly the first sign of expanded intracranial pressure.
A patron identified with bacterial meningitis is admitted to the unit and is prescribed neuro
exams each 2 hours. Which manifestation would the practical nurse screen for that might offer
the primary indication of altered neurological function?
A. Change in level of awareness
b. Increasing muscular weakness
c. Changes in scholar length bilaterally
d. Progressive nuchal tension - ANS-a. Change in degree of attention
A lower or alternate inside the stage of attention is generally the first indication of neurological
deterioration.
A purchaser diagnosed with chronic obstructive pulmonary ailment complains to the practical
nurse of excessive fatigue after coughing. Which self-care measures can help minimize the
consumer's dyspnea? (Select all that practice.)
a. Assume a sitting role with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and vicinity both feet flat on the ground.
C. Slightly drop the top, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up instantly, the use of diaphragmatic respiration to inhale slowly and deeply.
E. Repeat breathing in deeply and slowly with pursed lips even as bending forward handiest
once.
F. Repeat exhaling and watch for the cough reflex to facilitate movement of the secretions.
G. After coughing, inhale deeply from abdomen and cough 3 or 4 times while exhaling. - ANS-a.
Assume a sitting position with shoulders comfortable and knees flexed.
B. Support forearms with a pillow and place both toes flat at the ground.
C. Slightly drop the top, bend forward, and slowly exhale with pursed lips.
D. Resume sitting up immediately, the use of diaphragmatic respiratory to inhale slowly and
deeply.
, Effective coughing can help the customer to cough secretions, therefore enhancing gas trade
and reduce fatigue. The patron have to assume the sitting position with shoulders comfortable
and knees flexed. Their forearms have to be supported with a pillow and both feet area flat at
the ground. The consumer should barely drop their head, bent forward, and slowly exhale via
pursed lips the usage of gradual and deep diaphragmatic respiratory to help facilitate powerful
coughing. The patron ought to repeat the previous steps or 3 instances. The consumer must
initiate the cough reflex, now not wait for it. The customer ought to additionally take a deep
abdominal breath before starting up a cough.
A client diagnosed with congestive coronary heart failure has developed growing pedal edema
and pulmonary edema. What nutritional modification is most vital for the realistic nurse (PN) to
enhance with this client?
A. Avoid excessive carbohydrate ingredients.
B. Decrease consumption of fat-soluble vitamins.
C. Decrease caloric consumption.
D. Restrict salt and fluid consumption. - ANS-d. Restrict salt and fluid intake.
Rationale:
Salt and fluid regulations are the first nutritional adjustments for a client who is retaining fluid as
manifested by edema and pulmonary edema.
A customer recognized with diabetes has a prescription of 5 gadgets of ordinary insulin and 15
units of NPH insulin. In which order ought to the realistic nurse put together to manage the
insulin?List in order the nursing actions to be accomplished.
Arrange the sequence alternatives in the appropriate order through assigning every option a
number of.
Perform hand hygiene according to facility policy.
Inject 5 gadgets of air into ordinary insulin vial.
Inspect insulin vials for type and expiration dates.
Inject 15 units of air into NPH insulin vial.
Withdraw 15 devices of NPH insulin from vial.
Withdraw 5 devices of ordinary insulin from vial. - ANS-1. Perform hand hygiene consistent with
facility coverage.
2. Inspect insulin vials for type and expiration dates.
3. Inject 15 gadgets of air into NPH insulin vial.
4. Inject 5 gadgets of air into ordinary insulin vial.
Five. Withdraw five gadgets of everyday insulin from vial.
6. Withdraw 15 devices of NPH insulin from vial.
Rationale:
The first nursing action is to perform hand hygiene. The subsequent motion is to inspect vials for
type and expiration dates after which add 15 gadgets of air to NPH insulin vial. Next upload 5
